A  clinicopathological study of  cholecystitis with special reference to  analysis of  cholelithiasis.

Dr. R. THAMIL SELVI. Dr.Pammy sinha,Dr. P.M. Subramaniam, Dr. P. G. Konapur, Dr.C.V.Prabha.

VINAYAKA MISSION KIRUPANANDA VARIYAR MEDICAL COLLEGE AND  VINAYAKA MISSION HOSPITAL

Abstract :

Gall stone disease is a common problem in elderly women, the incidence ranging from 10% to 20% of the world population.  In India , it is seven times more common in the north than  in the south. Gallbladder stones are known to produce histopathological changes in the gallbladder. It is also one of the predisposing factors for the development of cancer of the gallbladder.

 

Aim:

  1. To study the clinicomorphological spectrum of gall stone diseases.
  2. To find out the possible risk factors.A
  3. To find out the frequency / prevalence of different types of gall stones.

 

Materials & Methods:

 

Retrospective study analysis of all cholecystectomy specimens received   in the Department of pathology, Vinayaga Mission’s Kirubananda Variyar Medical college, Salem from January 2008 to May 2011. Histopathology of gall bladder diseases and  biochemical analysis of gall stones done.

 

Results:

 

The total number of   cholecystectomy specimens studied were  78. There were 65 cases of chronic calculous cholecystitis, the highest incidence of these being in the age group of  41-60years. In this males were 28 and  females were 50 .   All patients  underwent ultrasonagraphy to confirm the clinical diagnosis.  There were 13 cases of  acalculus cholecystitis. On morphological  analysis, the commonest  gall stone was pigment  type and the  commonest lesion  was chronic cholecystitis by histopathology.

 

Conclusion:

 

The morphological spectrum of gall stone disease   identifies  the possible risk factors like increasing age, female sex , multiparity and obesity. People who are at risk, may modify their diet to decrease the   risk. Regular exercise may also reduce the risk of gall stones.

Keywords: Cholecystectomy, Calculous cholecystitis and Biochemical analysis

 

Introduction:

Gall stone disease is a very common gastrointestinal disorder, present commonly in the western world1. 10% of the adults patients have asymptomatic gall stones. The prevalence varies with age, sex and ethnic group. Overall prevalence of gall stone disease was 3.2%. Prevalence increases with age from 21 years  to 80 years  and was higher in females than in males.  Gallstones can occur anywhere within the biliary tree, including the gallbladder and the common bile duct.Gallstones are hard, pebble-like deposits.  Gall stones vary in their composition, majority being cholesterol and remaining being mixed  and pigmented. Gallstones made out of cholesterol are by far the most common type. Stones are made from   excess bilirubin in the bile. Bile is a liquid made in the liver that helps the body  to digest fats. Bile is made up of water, cholesterol, bile salts, and other chemicals, such as bilirubin. Such stones are called pigment stones. Mixed and pigment stones are common in northern India2 .

The stones form when there is an imbalance or change in the composition of bile. The first factor that predisposes to stone formation  is how often and how well the gallbladder contracts; incomplete and infrequent emptying of the gallbladder may cause the bile to become overconcentrated and contribute to gallstone formation.

The second factor is the presence of proteins in the liver and bile that either promote or inhibit cholesterol crystallization into gallstones. Increased levels of the hormone estrogen as a result of pregnancy, hormone therapy, or the use of birth control pills, may increase cholesterol levels in bile and also decrease gallbladder movement, resulting in gallstone formation

Other factors are   parity, smoking, alcohol,  diabetes and overweight.

Symptoms  of gall stone diseases are pain in the right upper abdomen, fever, jaundice, abdominal fullness, clay-colored stools, nausea and vomiting.  Further complications of gallbladder disease include gallstone pancreatitis, gallstone ileus, biliary cirrhosis and gallbladder cancer. Gallstones may be as small as a grain of sand or they may become as large as an inch in diameter, depending on how long they have been forming. A stone blocking the opening from the gallbladder or cystic duct usually produces symptoms of biliary colic, which is right upper abdominal pain that feels like cramping.

Obstruction of the common bile duct is choledocholithiasis; obstruction of the biliary tree can cause jaundice, obstruction of the outlet of the pancreatic exocrine system can cause pancreatitis. Clinical  symptoms were confirmed by ultrasonagraphy of abdomen.

Now a days, laparoscopic cholecystectomy is the treatment of choice in most patients. Pathological changes vary  from inflammation to malignancy.

Exclusion criteria : Autolysed specimen and under the age of ten were excluded from the study.

 

Materials & Methods:  This is a  retrospective study  done, in the department of pathology,  Vinayaga Mission’s Kirubananda Variyar Medical college,Salem. Total of about   78  cholecystectomies   from Jan 2008 to  May 2011 were studied.  Clinical data and pathological data were reviewed. All  cholecystectomy specimens  received, were fixed in 10% formalin, submitted to detailed gross examination and  microscopy after hematoxylin and eosin staining. Sections were obtained from the fundus, body and neck of the gallbladder. The stones were powdered  using  a mortar and dissolved in different solvents depending on the type of chemical constituent to be analysed.

 

Gall stone analysis was done as per the procedure described by Varley Harold3   .

Results:

The total number of   cholecystectomy specimens studied were   78. In this study, age ranges from 11 to 70 years with a mean of  45.90.  The sex distribution in the study is shown in Table-2.  Gall bladder lesions are predominantly seen in females ( 47)  as compared to males (31). Multiparity was seen in 38 cases.

The commonest presenting feature was vague upper abdominal pain with or without associated nausea, vomiting and  jaundice is shown in  Table-3.  

 

Table 1: Age distribution

Age group (years) Females Males Total
11- 20 1 - 1
21-30 6 7 13
31-40 7 3 10
41-50 14 1 15
51-60 9 9 18
>61 3 5 8
Total 40 25 65

 

In this males were 28,and females were 50.

Table 2:-  Sex distribution

Gall stones Females 40
  Males 25
No Calculi   13

 Obesity was seen in 29 patients out of 78 cases.

 

Presenting symptoms

No Symptoms Frequency  
1 Epigastric pain 12  
2 Right Hypochondrial Pain 40  
3 Nausea 13  
4 Vomiting 10  
5 Jaundice 3  

 

Table 3:- Classification of gall stones on the basis of their morphology.

 

Type of stone Morphology Number of cases as per gross morphology Number of cases as per Biochemical analysis
Cholesterol Solitary,oval,large & yellow 10 5
Pigment Multiple, small, jet black & mulberry shape 47 25
Mixed Multiple, multifaceted & size varies 8 35
No stones - 13 -
       

 

There were 65 cases of chronic calculous cholecystitis, the highest incidence of these being in the age group 41-50years.

There were 13 cases of chronic cholecystitis without calculus. On morphological  analysis, gall stones of mixed type were 35(53.8%),pigment type were 25(38.4%), and  cholesterol type were 5(7.6%).  Other lesions noted were  acute cholecystitis seen in 2 patients, granulomatous cholecystitis-1, eosinophilic cholecystitis-4, empyema-1 and carcinoma-1.

 

Table 4:- Lesions associated with cholecystitis

Lesions Cases Percentage
Acute cholecystitis 2 2.5
Chronic cholecystitis 67 87
Polyp 2 2.5
Granulomatous Cholecystitis 1 1.2
Empyema 1 1.2
Eosinophilic cholecystitis 4 3.8
Carcinoma 1 1.2

 

 

Morphological features of stones such as size, shape, number, texture and cross-section were noted.

Out of  78 patients, 11 cases had single stones and  54 cases had multiple stones. The gall stones size varied from 0.3cm to 2cm in diameter. The weight of gall stones   ranged from 0.3gm to 5gm. The stones are divided into 3 groups depending upon their color, varied from yellow and white stones  identified as cholesterol stones,  dark brown and black  as pigment stones  and brownish yellow or green as mixed stones.

 

On gross examination, it was found that outer gallbladder surface was congested in 2 patients (2.5%),wall thickness was increased in 43 (55.12%) and polyp  in 2 patients (2.5%).

In 31 (39.7%) patients no specific underlying cause was found on laboratory and clinical work-up.

Twenty six patients had diabetes mellitus while two patient had a family history of gall stones. In our study, 30 patients were  overweight.

 

Discussion:  Gallstone disease known as cholelithiasis is the most

common surgical disorder. Cholelithiasis is common with the incidence ranging

from 10% to 20% of the world population, 11% of the general population of the US1.

In our study, Total of about 78 cases, the mean age of presentation was 45.90.  In a Brazilian study, the age at presentation was 60.2 years 4.  The maximum patients being between 41-60 years (51 %).

In our study, Gall stone disease was   predominantly seen in females(61.5%) as compared to males(38.4%). Female sex hormones appear to play a role, especially between the ages of 20 and 30 years5 . Another study that researched oestrogen receptors and cholesterol biosynthesis found that oestrogen in particular stimulated the HMG-Co-A reductase enzyme causing increased synthesis of cholesterol  and thus putting women at an increased risk of supersaturation. Further supporting the link between estrogen and gallstones, it was determined that postmenopausal women on oestrogen replacement therapy were found to have an increased incidence of gallstones8. Progesterone may also contribute to gall stone disease by inhibiting gallbladder contraction and promoting hypomotility and gallbladder stasis.

Maskey CP et al  found that the commonest age group for cholelithiasis was below 30 years comprising 37.5%6. Our study correlated with studies conducted by Bockus et al7.

     Of the 47 females, 25 were of multiparous having 3 or more pregnancies. It is proved that increase in number of pregnancies is  associated with increased risk of gall stone as seen in world literature.  Parity also appears to be a factor in the development of gallstones. Women with more pregnancies and longer lengths of fertility periods appear to have a higher likelihood of developing gallstones than those who remain nulliparous.

A study in Chile found gallstones in 12.2% of multiparous women versus 1.3% of nulliparous women within the same age8,9.  Another study found women under the age of 25 years with > 4 pregnancies were 4 to 12 times more likely to develop cholesterol stones compared to nulliparous women of the same age and weight.

                Non-vegetarians were found to be more commonly involved with cholelithiasis than vegetarians. The ratio of incidence of cholelithiasis in non-vegetarians and vegetarians was found to be 8:2. The cause could be due to the consumption of high protein and fat. The findings were similar with the findings in a study done by Maskey et al in 1990 AD in Nepal where incidence of cholelithiasis was found more frequently among the people who consumed more fat and protein5 . In the similar study done by Katwal MR et al in Sikkim and North Bengal10.  In India, 97% cases of cholelithiasis were found in non-vegetarians.  

Obesity is an important risk factor for the development of gallstone diseases. Obese women, defined as a body mass index (BMI) > 30kg/m2) are at twice the risk of gallbladder disease than women with a normal BMI(<25kg/m2)11. Women with extreme obesity or a BMI >40kg/m2 have a 7-fold increased risk of gallstones 5,11.  The reason for the increased risk of gallstones in obese patients is due to an increased hepatic secretion of cholesterol 5,12.

In our study, obesity was seen in 39%. In this present study, the mean weight of the females was 55.8Kg.

     Abdominal pain was the most common presenting symptom. Gosh SK et al and Wani et al  observed tenderness in the right hypochondrial region as the most common

 sign 13,14.

 

Histopathological study showed   85.8 % of these patients suffering from chronic cholecystitis,  2.5%  with acute cholecystitis,  2.5% polyp, 1.2%  granulomatous cholecystitis, 1.2% empyema, 5.1% eosinophilic cholecystitis and  1.2% carcinoma.

 

Biochemical analysis of the stone showed n=37 (57%) of the cases had mixed stones, n=23(35.3%) had pigmented stones and only n=5(7.6%) had cholesterol stones.

 

Fifteen patients had history of alcoholism. Patients with chronic liver diseases are prone to develop pigment type of gall stone diseases.

 

Conclusion:- 

                  The most commonly involved age group for cholelithiasis (51%) is found to be 41- 60 years with a females being more common than males.  Cholelithiasis was found more commonly among non-vegetarians than  with vegetarians. Vegetarians to  non-vegetarian ratio was 2:8. Majority of the patients presented with right hypochondrial pain. Upper abdominal ultrasonography facilitates the  screening and early detection of gallstone disease. Chronic cholecystitis was the most common histopathological diagnosis. Mixed type stone was found to be the most common type of stone comprising 55%, followed by pigment stone and cholesterol stones. Early cholecystectomy is the treatment of choice in symptomatic patients.

 

References:-

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  3. Varley H In Practical Clinical Biochemistry 4th edition, CBS Publishers &  

      Distributors, New Delhi 1988;717-723.

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10.  Kotwal MR, Rinchen CZ. Gallstone disease in the Himalayas (Sikkim and North Bengal): causation and stone analysis. Indian J Gastroenterol. 1998. 17(3). 87-9.

11.  Sahi T, Puffenbarger  RS, Hseih  C, et al. Body mass index, cigarette smoking and other characteristics as predictors of selfreported, physician – diagnosed gallbladder disease in male college alumini. Am J Epidemiol. 1998;147:644-651.

12.  Shaffer EA, Small DM. Biliary lipid secretion in cholesterol gallstone disease. The effect of cholecystectomy and obesity. J Clin Invest. 1977;59:828-840.

13.  Gosh SK, Srinivasan TR, Natarajan VS, Tiwari BD. Pattern of presentation of symptomatic gall stones in North Indian population. Ind J Med Sci 2004; 11: 78-84.

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