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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 1-4

Clinical presentation of gallstone disease: Evidence from a case-control study


1 Department of Community Medicine, Dr Baba Saheb Ambedkar Medical College and Hospitals, Rohini, Delhi, India
2 Department of Community Medicine, LHMC and Associated Hospitals, New Delhi, India
3 Department of General Surgery, LHMC and Associated Hospitals, New Delhi, India

Date of Submission09-Sep-2019
Date of Acceptance10-Feb-2020
Date of Web Publication16-Apr-2020

Correspondence Address:
Dr. Manish K Goel
Department of Community Medicine, LHMC, New Delhi 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_26_19

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  Abstract 


Background: Gallstone disease (GSD) is defined as the presence of one or more stones in the gallbladder. Prevalence of GSD in the adult population ranges from 6% to 9% in India. The present study was aimed to know the association of abdominal symptoms and GSD.
Patients and Method: We conducted a case-control study from January 2013 to December 2013 among 120 cases and the same number of controls. Study subjects were selected from outpatient department (OPD) of general surgery. Data was collected by a self-designed pretested interview schedule, to assess sociodemographic profile, personal history, medical history, physical examination including anthropometry. Logistic regression was used for univariate and multivariate analysis to find out different symptoms and analyze the independent association of these symptoms with GSD.
Results: We enrolled 120 cases and the same number of age and sex matched controls. 69.2% of the cases were females and 30.8% were males. Univariate as well as multivariate logistic regression analysis of presenting symptoms among study subjects showed only intolerance to fatty food (P = 0.000) and epigastric or hypochondric pain (P = 0.000) were found to be statistically significantly associated with gallstone disease.
Conclusion: Biliary colic, consisting of sudden onset of pain in the epigastric or right hypochondric region lasting for more than 30 minutes is a good predictor of gallstone disease along with intolerance to fatty or spicy food.

Keywords: Abdominal symptoms, gallstone disease, right hypochondric pain


How to cite this article:
Dhamnetiya D, Goel MK, Dhiman B, Pathania OP. Clinical presentation of gallstone disease: Evidence from a case-control study. Arch Int Surg 2019;9:1-4

How to cite this URL:
Dhamnetiya D, Goel MK, Dhiman B, Pathania OP. Clinical presentation of gallstone disease: Evidence from a case-control study. Arch Int Surg [serial online] 2019 [cited 2020 Sep 19];9:1-4. Available from: http://www.archintsurg.org/text.asp?2019/9/1/1/282575




  Introduction Top


Gallstone disease (GSD) is defined as the presence of one or more stones in the gallbladder. Prevalence of GSD in the adult population ranges from 6% to 9% in India.[1],[2] Majority of gallstones are asymptomatic (80%) so-called “silent stone.” Most of them were found incidentally when the clinician performs abdominal ultrasound for another reason.[3] Risks of development of symptomatic gallstones in these patients were averaging 2% to 3% per year, 10% by 5 years.[4] Symptoms of gallstone disease include biliary colic (sudden onset pain in the epigastric region or right upper quadrant of the abdomen), belching, heartburn, nausea, vomiting, epigastric discomfort, and intolerance to fatty food.[3],[5],[6],[7],[8] Other than biliary colic most of the symptoms of GSD are nonspecific. The identification of symptoms associated with GSD might help physicians in decision making. Therefore, the aim of this study was to establish the association between abdominal symptoms and GSD.


  Patients and Method Top


To address the above objective, we conducted a case-control study from Jan 2013 to Dec 2013 among subjects attending OPD of general surgery in a teaching hospital of north India. The sample size was calculated using Fleiss formula[9] and assuming cases to control ratio 1:1 and for power of 80% and level of significance of 95% with an assumption of prevalence of some less common risk factors as 14%.[10]



n2= r n1

Where: n1= number of cases, n2= number of controls, Zα/2= standard normal deviate for two-tailed test based on alpha level (relates to the confidence interval level) (i.e,1.96 at 95% confidence interval), Zβ= standard normal deviate for one-tailed test based on beta level (relates to the power level) (Z1-β value at 80% power is 0.84), r = ratio of controls to cases, p1= proportion of cases with exposure (30%) and q1 =1-p1 (70%), p2= proportion of controls with exposure (14%) and q2 =1-p2 (86%).

Final calculated sample size was 116 subjects in each group, though we recruited 120 cases and the same number of controls in the study. Study subjects were selected from OPD of general surgery. Cases:Consecutive ultra-sonography confirmed cases of gallstone disease aged 20 years or more presenting in the OPD were enrolled in the study. Seriously ill gallstone disease patients, i.e, patients with complications like gallstone ileus, acute biliary pancreatitis, gallbladder carcinoma, porcelain gallbladder, and recurrent pyogenic cholangitis, patients who had psychiatric problems, and patients who did not give consent were excluded from the study. Controls: Patients above 20 years of age presented to surgical OPD and diagnosed negative for gall stones by ultra-sonography were taken as control and matched for age and sex. Pregnant females and patients who did not give consent were excluded. Data Collection: Data was collected by a self-designed pretested interview schedule to assess sociodemographic profile, personal history, medical history, physical examination including anthropometry. Patients were asked past 1-year history of following symptoms: belching, heartburn, nausea, vomiting, intolerance to fatty foods, epigastric discomfort, and abdominal pain. Furthermore patients who presented with abdominal pain were asked questions regarding characteristics of the pain characteristics of the pain: localization (on a diagram of the abdomen); radiation (back or right shoulder), duration and tolerability (forcing to rest); use of analgesics to relieve the pain; relieved by bowel movement and relationship with meals. In the present study, we have defined biliary colic as sudden onset of pain in the epigastric or right hypochondric region. All the subjects were investigated for biochemical parameters and anthropometric indices were calculated for all cases and controls using standard definitions.[11],[12] Abdominal ultrasound was performed by expert radiologist in the hospital.

Data management and statistical analysis

Data was recorded in MS Excel and Epi info 7 software was used for statistical analysis. Observations have been described in terms of mean and standard deviation for continuous data and in terms of percentages/proportions for categorical data. For comparison characteristics among study subjects, independent student's “t” test (t-test) was used. Logistic regression was used for univariate and multivariate analysis to find out different symptoms and analyze the independent association of these symptoms with GSD. Ethical Considerations: Ethical approval for this study was provided by the institutional ethical committee of Lady Hardinge Medical College and Associated Hospitals (letter no. LHMC/ECHR/2014/180), also an informed consent was obtained from each of the study subject.


  Results Top


We have enrolled 120 cases and the same number of age and sex matched controls in final analysis. 69.2% of the cases were females and 30.8% were males.

Comparison of characteristics using independent student's “t” test shows there were significant difference in the mean value of body mass index (BMI), waist hip ratio (W/H ratio), total cholesterol, triglycerides, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and duration of abdominal pain in cases as compared to control group. Mean age of cases and control was 45.74 ± 11.6 and 44.2 ± 10.9 years, respectively. Mean size of the largest stone among cases was 11.15 ± 6.2 mm [Table 1].
Table 1: Comparison of characteristics among study subjects using independent student’s “t” test

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Approximately, 2/3rd of the gallstone disease cases presented in surgical OPD with one or two symptoms followed by 1/5th of the cases with three symptoms and 10% cases with four symptoms. Only two cases presented with 5 symptoms. Abdominal ultrasound showed more than 2/3rd of the GSD cases had multiple stones and 32.7% had single stone. 54.2% of the cases had gallstones of ≤10 mm size and 45.8% cases had gallstones of >10 mm size. Among the cases those presented with abdominal pain, approximately, 2/3rd of them had pain lasting more than 30 min and in 36.8% of these cases pain lasted for ≤30 min [Table 2].
Table 2: Clinical characteristics of gallstone disease cases

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Univariate logistic regression analysis of presenting symptoms among study subjects shows only intolerance to fatty food (P = 0.000) and epigastric or hypochondric pain (P = 0.000) were found to be statistically significantly associated with gallstone stone disease. Other abdominal symptoms were also positively associated with GSD, but the association not statistically significant. We have further analyzed symptoms of GSD by using multivariate logistic regression; results were consistent with the findings of univariate logistic regression analysis, i.e, intolerance to fatty food (P = 0.000) and epigastric or hypochondric pain (P = 0.001) were statistically significantly associated with GSD [Table 3].
Table 3: Univariate analysis of symptoms of gallstone disease among study subjects

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[Table 4] shows univariate logistic regression analysis of pain characteristics among subjects with abdominal pain; only duration (more than 30 min) of abdominal pain was statistically significantly (P = 0.026) associated with GSD. Abdominal pain was found to be related to consumption of meal (Odd's Ratio = 2.1) and severe enough to force (OR = 1.53) gallstone disease patients to rest, but none of these characteristics of pain were statistically significantly associated with GSD. Further analyzing abdominal pain characteristics by multivariate logistic regression analysis also showed that none of the pain characteristics except for the duration (more than 30 min) (P = 0.037) were statistically significantly associated with GSD.
Table 4: Analysis of pain characteristics among subjects with abdominal pain (right hypochondric or epigastric pain)

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  Discussion Top


Over the last few decades, several researchers have studied clinical manifestation of GSD, most of the researchers found that biliary colic, i.e, sudden onset of pain in the epigastric or right hypochondric region was significantly associated with GSD.[3],[5],[6],[7],[13],[14],[15],[16],[17],[18],[19] In our study, we have also found that pain in epigastric or hypogastric region strongly associated with the GSD (OR = 3.51), whereas Jorgensen found no significant association between abdominal pain and GSD.[8] We have also found intolerance to fatty or spicy food strongly associated with GSD (OR = 3.06); this has been corroborated by several authors,[5],[13],[18] whereas Festi et al. found no significant association between intolerance to fatty or spicy food and GSD.[6] Among the other abdominal symptoms, we have found belching, heartburn, nausea, and vomiting were associated with GSD but no statistical difference was found; the same findings were seen by several other authors,[5],[7],[16],[17],[18],[19] but Festi et al. found no association between these abdominal symptoms and GSD.[6] In our study, epigastric discomfort was positively but not statistically associated with GSD, whereas Festi et al. and Jogersen found no association between epigastric discomfort and GSD.[6],[8]

In univariate as well as multivariate analysis, we have found that duration of abdominal pain more than 30 min was significantly associated with GSD. All other pain characteristics like tolerability (forcing to rest), radiating to right shoulder, relation with meal, consumption of analgesics to relieve pain, and pain relieved by bowel movement were not statistically associated with GSD. This has been correlated with findings of several other authors.[5],[6],[13],[18]


  Conclusion Top


Biliary colic consisting of sudden onset of pain in the epigastric or right hypochondric region lasting for more than 30 min is a good predictor of gallstone disease along with intolerance to fatty or spicy food. Other abdominal symptoms belching, heartburn, nausea, vomiting, and epigastric discomfort are nonspecific symptoms and cannot be used as GSD predictor. This has been recommended to physicians that whenever the patient presented in OPD with pain in abdomen and intolerance to fatty food, he/she should be advised for ultrasound for early diagnosis and management of gallstone disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khuroo MS, Mahajan R, Zargar SA, Javid G, Sapru S. Prevalence of biliary tract disease in India: A sonographic study in adult population in Kashmir. Gut 1989;30:201-5.  Back to cited text no. 1
    
2.
Unisa S, Jagannath P, Dhir V, Khandelwal C, Sarangi L, Roy TK. Population-based study to estimate prevalence and determine risk factors of gallbladder diseases in the rural Gangetic basin of North India. HPB (Oxford) 2011;13:117-25.  Back to cited text no. 2
    
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Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: Cholelithiasis and cancer. Gut Liver 2012;6:172-87.  Back to cited text no. 3
    
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Halldestam I, Enell EL, Kullman E, Borch K. Development of symptoms and complications in individuals with asymptomatic gallstones. Br J Surg 2004;91:734-8.  Back to cited text no. 4
    
5.
Littlefield A, Lenahan C. Cholelithiasis: Presentation and management. J Midwifery Womens Health 2019;64:289-97.  Back to cited text no. 5
    
6.
Festi D, Sottili S, Colecchia A, Attili A, Mazzella G, Roda E, et al. Clinical manifestations of gallstone disease: Evidence from the multicenter Italian study on cholelithiasis (MICOL). Hepatology 1999;30:839-46.  Back to cited text no. 6
    
7.
Traverso LW. Clinical manifestations and impact of gallstone disease. Am J Surg 1993;165:405-9.  Back to cited text no. 7
    
8.
Jørgensen T. Abdominal symptoms and gallstone disease: An epidemiological investigation. Hepatology 1989;9:856-60.  Back to cited text no. 8
    
9.
Fleiss JL, Levis B, Paik CM. Statistical Methods for Rates and Proportions. 3rd ed. New York: Wiley Interscience; 2003. p. 89-93.  Back to cited text no. 9
    
10.
National Family Health Survey for India conducted by. Mumbai, India: International Institute for Population Science; 2006. N.F.H.S.3rd.  Back to cited text no. 10
    
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Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. Harrison's Principles of Internal Medicine, 19th ed. New York: McGraw Hill Education; 2015. Available from: https://www.cmecde.com/download-harrison-principles-of-internal- medicine-19th-edition-pdf/. [Last assessed on 2019 May 22].  Back to cited text no. 11
    
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World Health Organization. The Asia Pacific Perspective; Redefining obesity and its treatment. Available from: http://www.wpro.who.int/nutrition/documents/docs/Redefiningobesity.pdf. [Last assessed on 2019 May 18].  Back to cited text no. 12
    
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Abraham S, Rivero HG, Erlikh IV, Griffith LF, Kondumudi VK. Surgical and nonsurgical management of gallstones. Am Fam Physician 2014;89:795-802.  Back to cited text no. 13
    
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Thomas S. Differentiating abdominal pain using Murphy's sign. Practice Nurs 2013;24:141.  Back to cited text no. 14
    
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Njeze GE. Gallstones. Niger J Surg 2013;19:49-55.  Back to cited text no. 15
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Berhane T, Vetrhus M, Hausken T, Olafsson S, Søndenaa K. Pain attacks in non-complicated and complicated gallstone disease have a characteristic pattern and are accompanied by dyspepsia in most patients: The results of a prospective study. Scand J Gastroenterol 2006;41:93-101.  Back to cited text no. 16
    
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Paracha PI, Asif Y, Vriesekoop F, Ullah S, Abbas M, Paracha SI, et al. Risk factors associated with gallstone disease in women. e-SPEN J 2012;7:e129-34.  Back to cited text no. 17
    
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Kalloo AN, Kantsevoy SV. Gallstones and biliary disease. Prim Care 2001;28:591-606.  Back to cited text no. 18
    
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Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: Cholelithiasis and cancer. Gut Liver 2012;6:172-87.  Back to cited text no. 19
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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