Saudi Surgical Journal

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 8  |  Issue : 4  |  Page : 185--191

Diagnostic and prognostic role of upper gastrointestinal endoscopy in cholelithiasis patients with upper gastrointestinal symptoms


Azeem Nasaruddin1, Dinesh Jain1, Kedar Patil1, Deepak Phalgune2,  
1 Department of Surgery, Poona Hospital and Research Centre, Pune, Maharashtra, India
2 Department of Research, Poona Hospital and Research Centre, Pune, Maharashtra, India

Correspondence Address:
Deepak Phalgune
18/27, Bharat Kunj -1, Erandawane, Pune - 411 038, Maharashtra
India

Abstract

Background: The aim of the present study was to find the utility of upper gastrointestinal (UGI) endoscopy in predicting the persistence of postoperative pain following laparoscopic cholecystectomy (LC) and to find the prevalence of other UGI pathologies before LC. Materials and Methods: Ninety patients ≥18 years of age who have gallbladder stones confirmed by ultrasonography were included in this prospective observational study. All patients were subjected to UGI endoscopy (UGIE) examination 1 day before operation. Postoperative follow-up was done on day 1, 14, and 30 for the symptoms. The primary outcome measure was the persistence of postoperative pain, whereas the secondary outcome measure was the prevalence of UGI pathology. The comparison of quantitative variables and qualitative variables was done using the unpaired Student's t-test and the Chi-square test/Fisher's exact test, respectively. Results: The majority of the patients (63.3%) had atypical symptoms. The incidence of the severity of postoperative pain at day 1, day 14, and day 30 did not differ significantly between typical symptoms group and atypical symptoms group. The postoperative pain at day 14 and day 30 was 62.9% versus 20.0% and 45.7% versus 5.5% in an abnormal UGIE group and normal UGIE group, respectively (P = 0.001 for both). In all 20 (22.2%), 9 (10.0%), 1 (1.1%), 2 (2.2%), and 3 (3.3%) had gastritis, deudenitis, gastric ulcer, deudenal ulcer, and gastrooesophageal reflux disease (GERD), respectively. Conclusions: Patients should undergo UGIE before LC to find the presence other UGI pathology.



How to cite this article:
Nasaruddin A, Jain D, Patil K, Phalgune D. Diagnostic and prognostic role of upper gastrointestinal endoscopy in cholelithiasis patients with upper gastrointestinal symptoms.Saudi Surg J 2020;8:185-191


How to cite this URL:
Nasaruddin A, Jain D, Patil K, Phalgune D. Diagnostic and prognostic role of upper gastrointestinal endoscopy in cholelithiasis patients with upper gastrointestinal symptoms. Saudi Surg J [serial online] 2020 [cited 2022 Jan 20 ];8:185-191
Available from: https://www.saudisurgj.org/text.asp?2020/8/4/185/334514


Full Text



 Introduction



Laparoscopic cholecystectomy (LC) is a gold standard surgery for symptomatic gallstone disease which is the most common disease that needs surgical management. Cholecystectomy can be curative only if the symptoms are due to gallstones and not due to other upper gastrointestinal (UGI) pathologies. It causes unnecessary burden of cost and surgical risk to patient and delays definitive treatment for the actual cause.[1]

Cholelithiasis can present with a complex combination of UGI symptoms which may resemble the presentation of other UGI diseases.[2] The most considerable challenge in the assessment of patients with UGI symptoms, who are found to have gallstones, is whether stones are the source of the symptoms, or are the incidental findings.[3] Distinguishing between these two situations is crucial, as both gallstones and UGI symptoms are common in the general population. Persistent postcholecystectomy pain called “postcholecystectomy syndrome” is reported in 20.0%–30.0% of patients.[4] The relationship between such persistent pain and cholelithiasis is often unclear. Coexistence of concurrent UGI problems with gallstones may have attributed to the postcholecystectomy syndrome. Differentiating between these two situations is important, because the prevalence of both the conditions is common in the general population.

A proportion of patients do not get symptomatic relief after cholecystectomy as there is an overlap in the symptomatology of biliary and gastroduodenal pathologies.[5],[6] Studies reported coexistent diseases mainly gastroesophageal reflux, peptic ulcer, hiatus hernia, gastritis, constipation, inflammatory bowel syndrome, anterior cutaneous nerve entrapment syndrome, fatty liver disease, chronic obstructive pulmonary disease, or coronary artery disease ranging from 1.0% to 65.0% as the etiology for long-term persistent abdominal symptoms after LC.[7],[8] Misinterpretation of the symptoms and suboptimal indication for LC would result in persistent symptoms after surgery.[7],[9],[10],[11],[12],[13],[14] Even if the indication for the LC was made correctly and the biliary symptoms are resolved, symptoms of a coexistent disease can become more prominent and considered as persistent symptoms after LC.[15]

Hence, it is better to carry out UGI endoscopy (UGIE) to find other pathologies in addition to gallstones. There is a paucity of data available in the published literature on the utility of UGIE in predicting the persistence of postoperative pain following LC from India. The aim of the present study was to find the utility of UGIE in predicting the persistence of postoperative pain following LC and to find the prevalence of other UGI pathology using UGIE before LC.

 Materials and Methods



This prospective, observational study was conducted between May 2020 and February 2021. After approval from the Institutional Ethics Committee (Letter No. IEC/2020/52), a written informed consent was obtained from all the patients before enrollment explaining the risks and benefits of the procedure. Patients ≥18 years of age who have gallbladder stones confirmed by ultrasonography were included. Patients with choledocholithiasis, obstructive jaundice, cholangitis, gallstone pancreatitis, gallbladder neoplasm, and previous history of biliary/pancreatic surgery were excluded.

Detailed history and clinical examination were conducted of every patient. The presence of gallstones was confirmed on ultrasonography (GE Healthcare LOGIQ™ P9 Ultrasound system, USA). The ultrasonography findings, reports of endoscopic evaluation of mucous membrane of the esophagus, stomach and duodenum, the results from rapid urease test (RUT), and histopathologic examination (HPE) of biopsy specimens were noted of each patient.

For the present study, the typical pain was defined as recurrent sudden onset rapidly increasing that commonly fires after a fatty meal, situated in the right upper quadrant or mid epigastrium and radiated to the right scapula and back.[16] The pain was assessed using visual analogue scale (VAS) score and classified as no pain, mild, moderate, and severe pain. Atypical symptoms were defined as any epigastric abdominal discomfort that did not fulfil typical pain criteria.[16]

All symptomatic patients with gallstones whether experienced typical or atypical symptoms were subjected to UGIE examination 1 day before operation in the endoscopy room. Endoscope used was model No. EG-590 WR, from Fujinon Corporation, Japan. The endoscopic samples were taken for RUT and HPE in all the patients. Biopsy was obtained from the antrum, and the body of the stomach and was examined for HPE. Similarly, cholelithiasis patients associated with UGI symptoms with preoperative UGI lesions on endoscopy were subjected to LC following standard protocol of the institution. All the patients were followed-up postoperatively on day 1, 14, and 30 for the symptoms either personally in OPD or through phone.

Patients were told about the VAS score preoperatively and asked to mark on the horizontal 100 mm line with word descriptions, the point that they feel represents their perception of their current pain during follow-up. Using a ruler, the score was determined by measuring the distance (mm) on the 10 cm line between the “no pain” anchor and the patient's mark, providing a range of scores from 0 to 100.[17] The pain severity was classified according to the recommended cut points on the VAS score: No pain (0–4 mm), mild pain (5–44 mm), moderate pain (45–74 mm), and severe pain (75–100 mm).[18]

The primary outcome measure was the persistence of postoperative pain following LC, whereas the secondary outcome measure was the prevalence of other UGI pathology. On the basis of the previously published study, 11/400 (2.8%) patients experienced residual abdominal pain following LC.[19] A sample size of 42 patients was calculated by formula N[20] = Zα2p (1-p)/d2 with 80% power and 5% probability of Type I error to reject the null hypothesis. We included 90 patients to validate the results.

Data collected were entered in Excel 2007 and analysis of data was done using Statistical Package for the Social Sciences software for Windows, version 20.0 from IBM Corporation, Armonk, NY, USA. The data on categorical variables are shown as n (% of cases), and the data on continuous variables are presented as mean and standard deviation. The comparison of quantitative variables and qualitative variables between the groups was done using the unpaired Student's t-test and the Chi-square test or Fisher's exact test, respectively. The underlying normality assumption was tested before subjecting the study variables to unpaired Student's t-test. The confidence limit for significance was fixed at 95% level with a P < 0.05.

 Results



Of 90 patients, 39 (43.3%) and 51 (56.7%) were men and women, respectively. Of 90 patients, 8 (8.9%) and 4 (4.4%) had diabetes mellitus and hypertension, respectively. UGIE findings showed that of 90 patients, 20 (22.2%), 9 (10.0%), 1 (1.1%), 2 (2.2%), and 3 (3.3%) had gastritis, deudenitis, gastric ulcer, deudenal ulcer, and GERD respectively. RUT was positive in 16 (17.8%) and negative in 74 (82.2%) patients. HPE were abnormal in 35/90 (38.9%) patients. Of 90 patients, 23 (25.6%), 9 (10.0%), 1 (1.1%), and 2 (2.2%) had gastritis, deudenitis, gastric ulcer, and deudenal ulcer, respectively on HPE. Of 35 patients with UGI pathology by HPE, 16 (45.7%) had Helicobacter pylori infection.

We divided patients into two groups: typical symptoms group and atypical symptoms group and compared the various findings. Of 90 patients, 33 (36.7%) and 57 (63.3%) had typical and atypical symptoms, respectively. There was no statistically significant difference between typical symptoms and atypical symptoms groups in relation to the mean age, gender, comorbidity, UGIE findings, HPE findings, and RUT positivity [Table 1].{Table 1}

The incidence of the severity of postoperative pain at day 1, day 14, and day 30 did not differ significantly between typical symptoms group and atypical symptoms group [Table 2]. We compared the severity of postoperative pain in typical and atypical symptoms groups whose UGIE was normal and abnormal. The postoperative pain in typical symptoms group at day 14 did not differ significantly between the two groups whose UGIE was normal and whose UGIE was abnormal, whereas the postoperative pain at day 30 was significantly higher in abnormal UGIE group as compared to normal UGIE group [Table 3]. The postoperative pain in atypical symptoms group at day 14 and day 30 was significantly higher in abnormal UGIE group as compared to normal UGIE group [Table 4]. The postoperative pain of all the patients (typical symptoms group and atypical symptoms group) at day 14 and day 30 was significantly higher in abnormal UGIE group as compared to normal UGIE group [Table 5].{Table 2}{Table 3}{Table 4}{Table 5}

 Discussion



In the present study, the persistence of abdominal pain after LC was significantly higher in patients with abnormal UGIE findings as compared to normal UGIE findings. Gastritis was the most common (22.2%) UGI pathology.

The symptoms of gallstones can be variable ranging from nonspecific to acute medical emergency. Patiño et al. reported that 80.0% of patients with cholelithiasis were asymptomatic and that the patients appear to be symptomatic at the rate of 2.0%–3.0% per year.[21] It was reported that 2.0% patients have an overall risk of biliary complications such as acute pancreatitis and acute choledocholithiasis and 0.02% have the risk of the incidence of gallbladder cancer.[22],[23]

Romero et al. reported that among symptomatic patients, half of the patients develop biliary colic within a year.[24] Berger et al. reported that though, biliary colic is specific for gallstones, most of the patients present with other abdominal symptoms.[25] Schirmer et al. opined that ruling out other causes of pain before cholecystectomy, prior UGIE will not only decrease persistence of symptoms, but can also be helpful in detecting gastroduodenal pathologies at an early stage.[26]

In the present study, 63.3% and 36.7% patients had atypical and typical biliary colic symptoms respectively. A study conducted in Madhya Pradesh, India reported that 98 (42.5%) and 118 patients (57.5%) had typical symptoms and atypical symptoms respectively.[27] Chandio et al. reported that 146 (38.22%) patients presented with typical pain and 236 (61.78%) with atypical pain.[28]

In the present study, gastritis (22.2%) was the most common finding in UGIE and HPE. Chandio et al. reported that preoperative UGIE findings revealed esophagitis, gastro-esophageal reflux disease (GERD), gastritis, gastric ulcer, duodenal ulcer, polyps and carcinoma of stomach in 22 (5.75%), 26 (6.80%), 88 (23.03%), 49 (12.82%), 39 (10.20%), 21 (5.49%) and 9 (2.35%) patients, respectively.[28] A study conducted in Karnataka, India, reported that out of 100 subjects who underwent UGIE, 44.0% of the patients were found to have normal mucosal study. The study further stated that the most common endoscopic finding was GERD (n = 31), followed by gastroduodenal ulcer (n = 19) and gastroduodenitis (n = 11); other endoscopic findings were hiatus hernia (n = 5), gastricpolyposis (n = 3), and esophagitis (n = 2).[29] A study conducted in Gujrat, India, reported that the most common site of pathology was gastritis (72.5%), followed by esophagitis (55.0%), and hiatus hernia (16.5%), whereas the most common duodenal pathology was duodenitis (6.25%).[30] Thybusch et al. reported that 25.7%, 6.8%, 1.8%, 3.2%, 4.7%, 3.0%, and 0.6% had gastritis, peptic ulcers, gastric erosions, polyps, hiatal hernias, esophagitis, and gastric cancer, respectively.[31] Sosada et al. reported that 735 (26.3%), 127 (4.5%), 179 (6.4%), 143 (5.1%), and 3 (0.1%) had gastritis, duodenal ulcer, gastric ulcer, polyps, and cancer, respectively.[32] A study conducted in Jammu, India, reported gastritis in 18 (60.0%) patients.[33]

Thybusch et al. reported that 50.0% of patients undergoing endoscopy before cholecystectomy had pathological findings and management plan changed in 8.3% of patients. The study further stated that the patients had to be treated medically and that the cholecystectomy was postponed.[31] A study conducted in the UK suggested that the routine use of UGIE helped to reduce the overall cholecystectomy rates with beneficial clinical and economical outcomes.[34] A study conducted in Ireland compared a group of patients who underwent UGIE and a group without UGIE before cholecystectomy. The study stated that the use of preoperative UGIE had no significant benefit in decreasing the postoperative residual abdominal pain.[19]

A study conducted at a single teaching hospital in Mumbai reported that of 60 patients who underwent UGIE, GERD, antral gastritis, duodenal ulcer, gastric erosions, biliary reflux from duodenum into the stomach was observed in 14 (23.33%), 10 (16.66%), 8 (13.33%), 4 (6.66%), and 3 (5.0%) patients, respectively, whereas rest of the endoscopy were normal in 21 (35.0%) patients.[35] In the present study, HPE after endoscopic biopsies showed that majority (25.6%) had gastritis. A study conducted at a single teaching hospital in Mumbai, reported that endoscopic biopsies for H. pylori infection and RUT were done. The study further stated that biopsy was positive for H. pylori in 12 (70.58%) patients.[35] In the present study, of 35 patients with UGI pathology by HPE, 16 (45.7%) had H. pylori infection.

A study conducted in Madhya Pradesh, India in patients with typical pain and normal UGIE reported that the patients had a complete relief of symptoms within 1 week postoperatively. The study further stated that the patients with atypical pain had persistence of symptoms, which were relieved on specific treatment and lifestyle changes.[27] A study conducted in Jammu, India, stated that all patients with persistence of symptoms beyond 1 and 3 months had abnormal endoscopic findings preoperatively.[33] Chandio et al. reported that in all the patients with typical pain complete relief of symptoms were observed within 15 days postoperatively. The study further stated that of 236 (61.78%) patients with atypical pain, 141 (59.74%) had persistence of symptoms up to 4 months.[28] A study conducted in the UK reported that patients who did not undergo endoscopy before the cholecystectomy, the recurrence or persistence of symptoms was 20/61 (32.78%), whereas the patients who underwent endoscopy before the cholecystectomy 35.0% of the patients had positive findings, which were treated for the pathology and only 2 (3.3%) had recurrence or persistence of symptoms.[34] A study conducted in Gujrat, India, reported that in all the patients with normal preoperative UGIE findings, the patients had a complete relief of symptoms within 1 week.[30]

In the present study, the persistence of mild pain was higher in patients in atypical group of patients who had abnormal findings in the UGIE which suggests that doing UGIE is helpful in early detection of UGI pathologies and timely management. A study conducted in Ireland, compared a group of patients who underwent UGIE before cholecystectomy and a group of patients without UGIE before the surgery. The study reported that the use of preoperative UGIE had no significant benefit in decreasing the postoperative residual abdominal pain. The authors have concluded that UGIE can disclose other gastro-esophageal disorders with similar symptoms to gallstones and may change the course of the planned surgery in chronic cholecystitis.[19]

Limitations

Postoperatively, the patients were followed up for only 30 days. It was a single-center study conducted on limited patient population of 90; hence, these results cannot be extrapolated to large population. All patients irrespective of UGIE findings underwent LC. Multicentric studies with a large sample size and long-term follow-up should be undertaken to substantiate the research findings described in this article.

 Conclusions



The majority (63.3%) of the patients had atypical symptoms. In all 20 (22.2%), 9 (10.0%), 1 (1.1%), 2 (2.2%), and 3 (3.3%) had gastritis, deudenitis, gastric ulcer, deudenal ulcer, and GERD, respectively. The incidence of the severity of postoperative pain at day 1, day 14, and day 30 did not differ significantly between typical symptoms group and atypical symptoms group of patients. The postoperative pain in typical symptoms group at day 30 was significantly higher in abnormal UGIE group as compared to normal UGIE group. The postoperative pain in atypical symptoms group of patients at day 14 and day 30 was significantly higher in abnormal UGIE group as compared to normal UGIE group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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