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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 25-28

An evaluation of the gallbladder in adult sickle cell anemia patients in Zaria North-West Nigeria


1 Department of Haematology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria
2 Department of Chemical Pathology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria
3 Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria

Date of Web Publication13-Mar-2015

Correspondence Address:
A Hassan
Department of Haematology, Ahmadu Bello University Teaching Hospital, PMB 06 Shika Zaria, 810 001, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.153146

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  Abstract 

Background: Sickle cell anemia (SCA) is characterized by a constant state of hemolysis which leads to hyperbilirubinemia. Hyperbilirubinemia may predispose to development of pigment gallstones in these patients. Gallstones in SCA patients increase morbidity and mortality and poses diagnostic dilemma as most patients are asymptomatic. The objective of this study was to evaluate the gallbladder using ultrasonography, biochemical, and hematological parameters among adult SCA patients in steady state at the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria.
Patients and Method: We conducted a case-control cross-sectional study of adult SCA patients attending the hematology clinic of ABUTH, Zaria, Nigeria and HbAA controls. Sixty-seven consenting adult SCA patients in steady state and twenty HbAA controls had abdominal ultrasonography, biochemical, and hematological tests on blood samples. Information obtained was entered and analyzed using Statistical Package for the Social Sciences (SPSS) 17.0. Statistical evaluation consisted of descriptive analysis and comparison of means using student's t-test. Level of significance was set at P < 0.05.
Results: Of the 67 SCA patients, 19 (28.4%) had gallstones, and the prevalence increased with increasing age of the patients. There were significant differences in all laboratory parameters between SCA patients and the HbAA controls except alkaline phosphatase levels. While there were no significant differences in these parameters between SCA patients with gallstone and those without gallstone except the gallbladder volume. All the SCA patients with gallbladder stones were asymptomatic.
Conclusion: There is a high prevalence of gallbladder stone in SCA patients, especially after the age of 20 years. Thus, abdominal ultrasonography should be part of the routine care of SCA patients, especially after the second decade of life.

Keywords: Gallbladder, gallstones, sickle cell anemia, ultrasonography


How to cite this article:
Hassan A, Yusuf R, Babadoko A A, Ibinaiye P O, Aminu S M, Muktar H M. An evaluation of the gallbladder in adult sickle cell anemia patients in Zaria North-West Nigeria . Arch Int Surg 2015;5:25-8

How to cite this URL:
Hassan A, Yusuf R, Babadoko A A, Ibinaiye P O, Aminu S M, Muktar H M. An evaluation of the gallbladder in adult sickle cell anemia patients in Zaria North-West Nigeria . Arch Int Surg [serial online] 2015 [cited 2021 May 12];5:25-8. Available from: https://www.archintsurg.org/text.asp?2015/5/1/25/153146


  Introduction Top


The World Health Organization (WHO) estimates that approximately 5% of the world's populations carries the gene for hemoglobin disorders, mainly sickle cell disease (SCD) and thalassemia. [1] In Africa, 10-40% of the population carries the sickle cell gene with an estimated prevalence of 2% for SCD. [2] SCD is characterized by abnormal-shaped red blood cells (RBC) which have a shortened life span. [1],[2]

SCA is characterized by a state of chronic intravascular hemolysis and microvascular ischemia leading to multiple organ damage as a long-term sequel. [3] Continuous RBC destruction (hemolysis) leads to the release of hemoglobin which is broken down to biliverdin and, subsequently, bilirubin with the aid of the hepatic enzymes hemoxygenase. Bilirubin is then excreted in bile as part of the bile pigments. [4],[5] Several reports have shown that liver and gallbladder dysfunction are common in sickle cell patients with resultant production of pigment gallstones. The incidence of gallstones increases with age among HbSS patients. [6],[7]

This study was to evaluate the gallbladder using ultrasonography in steady state adult sickle cell anemia (SCA) patients and to determine any relationship between the gallbladder findings and hematological and biochemical parameters of these patients.


  Patients and Methods Top


This was a cross-sectional case-control study of 67 adult SCA (HbSS) patients (alkaline electrophoretic pattern) in steady state attending the hematology clinic were selected by convenient sampling method and 20 apparently healthy HbAA individuals as controls at of Ahmadu Bello University Teaching Hospital (ABUTH), Zaria. Ethical clearance was obtained from the Hospital Health Research Ethical Committee. All participants signed an informed written consent prior to enrolment.

The hematological (packed cell volume [PCV], white blood cell, platelet, and reticulocyte counts) and biochemical (total bilirubin and alkaline phosphatase) parameters were determined by automated hematology (Sysmex 2000i, Japan) and chemistry (Selectra XL by Elitech, USA) analysers, respectively. Participants gallbladder where ultrasonically evaluated by a consultant radiologist using B-mode ultrasound machine (Aloka SSD-3500 by Hitachi, Japan) with the patient in supine right-sided oblique position. Data obtained were analyzed using Statistical Package for the Social Sciences (SPSS) version 17.0 software. Descriptive statistics and t-test were used in making inferences. A P value of ≤0.005 was set as the level of significance.


  Results Top


The mean ages of the participants and controls were 24.1 ± 4.7 years and 22.7 ± 1.2 years (P = 0.192), respectively. Out of the 67 study participants, 19 (28.4%) had gallstones while none of the controls had gallstones. The prevalence in males and females was 3/28 (10.7%) and 16/39 (41%), respectively (P = 0.141). The male to female ratio of SCA patients with gallstones was 1:5.3, while the mean and standard deviation (SD) of the biochemical and hematological parameters in the SCA patients and controls are presented in [Table 1]. The mean and SD of the hematological and biochemical parameters of SCA with gallstones and those without gallstones are presented in [Table 2]. The prevalence of gallstones per age group is shown in [Table 3].
Table 1: Haematological and biochemical parameters of SCA patients and control


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Table 2: Haematological and biochemical parameters of SCA patients with or without gallstones


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Table 3: Prevalence of gallstones in SCA patients by age group


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  Discussion Top


The overall prevalence of gallstones in adult SCA patients in steady state in this study is 28.4% which is slightly higher than the 24.2% reported by Durosinmi et al. in South-West Nigeria. [8] This difference may be related to the higher mean atmospheric temperature in the North-West (40-45 0 C) as compared to the South-West (35-40 0 C) zones of Nigeria. [9] This difference in temperature may predispose to dehydration and thus concentration of bile which could increase the incidence of gallbladder stones in the patients from the North of Nigeria. There was a higher prevalence among female patients than males 5.3:1 similar to the report by Agholor et al. (7.9:1) in Benin, South-South Nigeria and Akinyanju et al. in Lagos, South-West Nigeria.

Gallstones commonly result from chronic hemolytic episodes. Hemolysis is partly supported by the marked reticulocytosis of 10% in SCA patients with gallstones compared to the 8% in those without gallstone in this study. However, in contrast to our findings Akinyanju et al. also in South-West Nigeria reported a gallstone prevalence of 9% in SCA patients. This may be attributable to the inclusion of both pediatric and adult age-group. [10] Another study from South-South Nigeria by Agholor et al. reported an overall prevalence of 16% and an increasing prevalence of gallstones with increase age such that SCA patients of 21-30 years had a prevalence of 30.8% and while those of 31-40 years had 57.1% prevalence [11] comparable with our finding of 35% prevalence in those aged 21-30 years and 42.9% in those 31-40years. The increasing incidence of gallstones with age may be attributable to the chronic hemolysis and frequent use of antibiotics such as the quinolones for the treatment of infections in adult SCA patients. Billa et al. working in Cameroun reported an overall prevalence of gallstones in SCA patients at 28.9% which was commoner after 40 years of age with a prevalence of 75% of those patients. [12] Similarly, a British study by Bond et al. also demonstrated a prevalence of 83% in SCA patients aged 30 or more years, [13] these findings are remarkably higher than the 42.9% prevalence in patients over 40 years of age in our study.

Though, it is hypothesized that hyperbilirubinemia arising from constant hemolysis in SCA may be responsible for the formation of pigment gallstones, the elevated total bilirubin of 36.7 μmol/L in SCA patients with gallstones compared to 25.5 μmol/L in those without gallstones supports the hypothesis. However, there is no statistical difference in all the hematological and biochemical parameters between the SCA patients with and those without gallstones particularly total bilirubin, in conformity with other reports that found no difference in laboratory parameters between SCA patients with or without gallstones. [12],[13],[14] This may thus signify that other factors such as liver and gallbladder abnormalities may be responsible for development of gallstones in SCA patients. [15]

Interestingly, though there was a high prevalence of gallstones among the study participants, they were asymptomatic. This asymptomatic clinical state is explainable by the concept of asymptomatic gallstone or silent gallstones in which patients with variable clinical conditions including SCA with detectable gallstones on ultrasonography but without clinical symptoms. These silent gallstones may lead to diagnostic dilemma in SCA abdominal pain crises. [16] Even though some workers advocate prophylactic cholecystectomy, majority of physicians oppose this because of the likely high morbidity and mortality that may accompany surgical intervention and thus patients should continue their routine care. [17],[18]


  Conclusion Top


There is a high prevalence of gallbladder stones in SCA patients in Zaria especially after the age of 20 years. We therefore advocate that SCA patients should undergo annual abdominal ultrasonography to assess their gallbladder to detect and treat such complications promptly.


  Acknowledgement Top


We acknowledge the assistance of resident doctors in Hematology, Chemical Pathology and Radiology Departments in the selection and care of SCA patients during the study.

 
  References Top

1.
WHO. Sickle-cell disease and other haemoglobin disorders. Geneva: WHO; 2011. p. 1-2. Available from: http//www.who.int/gb/ebwha/pdf [Last accessed on 2014 Oct 15].  Back to cited text no. 1
    
2.
WHO. Sickle-cell disease: A strategy for the WHO African Region. Geneva: WHO; 2010. p. 1-9. AFR/RC60/8/PDF  Back to cited text no. 2
    
3.
Aliyu ZY, Tumblin AR. Current therapy of sickle cell disease. Haematologica 2005;90:7-10.  Back to cited text no. 3
    
4.
Ganong WF. Circulating body fluids. In: Ganong WF, editor. Review of Medical Physiology. 22 nd ed. Boston: McGraw Hill; 2005. p. 515-46.  Back to cited text no. 4
    
5.
Ganong WF. Gastrointestinal function. In: Ganong WF, editor. Review of Medical Physiology. 22 nd ed. Boston: McGraw Hill; 2005. p. 467-514.  Back to cited text no. 5
    
6.
Konote-Ahulu FID. Pallor and jaundice in sickle cell disease. In: The Sickle Cell Disease Patient; 1980. p. 171-88.  Back to cited text no. 6
    
7.
Serjeant GR, Serjeant SB. The liver and gallbladder. In: Sickle Cell Disease. 3rd ed. Oxford: Oxford University Press; 1985. p. 131-48.  Back to cited text no. 7
    
8.
Durosinmi MA, Ogunseyinde AO, Olatunji PO Esan GJ. Prevalence of cholelithiasis in nigerians with sickle cell disease. Afr J Med Med Sci 1989;18:223-7.  Back to cited text no. 8
    
9.
Nigerian Meteorological Agency. Nigerian Climate Bulletin 2010. Abuja: Nigerian Meteorological Agency; 2010.  Back to cited text no. 9
    
10.
Akinyanju O, Lagunju F. Cholelithiasis and biliary tract disease in sickle-cell disease in Nigerians. Postgrad Med J 1979;55:400-2.  Back to cited text no. 10
    
11.
Agholor CA, Akhigbe AO, Atalabi OM. The prevalence of cholelithiasis in Nigerians with sickle cell disease as diagnosed by ultrasound. Br J Med Med Res 2014;4:2866-73.  Back to cited text no. 11
    
12.
Billa RF, Biwole MS, Juimo AG, Bejanga BI, Blackett K. Gall stone disease in African patients with sickle cell anaemia : A preliminary report from Yaounde, Cameroon. Gut 1991;32:539-41.  Back to cited text no. 12
    
13.
Bond LR, Hatty SR, Horn ME, Dick M, Meire HB, Bellingham AJ. Gall stones in sickle cell disease in the United Kingdom. Br Med J (Clin Res Ed) 1987;295:234-6.  Back to cited text no. 13
    
14.
Attalla B, Karrar ZA, Ibnouf G, Mohamed AO, Abdelwahab O, Nasir EM, et al. Outcome of cholelithiasis in Sudanese children with Sickle Cell Anaemia (SCA) after 13 years follow-up. Afr Health Sci 2013;13:154-9.  Back to cited text no. 14
    
15.
Attalla BI. Abdominal sonographic findings in children with sickle cell anaemia. J Diagn Med Sonogr 2010;26:281-5.  Back to cited text no. 15
    
16.
Matthews M. Cholelithiasis: A differential diagnosis in abdominal "crisis" of sickle cell anemia. J Natl Med Assoc 1981;73:271-3.  Back to cited text no. 16
    
17.
Meshikes NA. Asymptomatic gallstones: To treat or not to treat? Gastroenterol Hepatol 2014;1:14-6.  Back to cited text no. 17
    
18.
Gupta SK Shuvla SV. Silent gallstone: A therapeutic dilema. Trop Gastroenterol 2004;25:65-8.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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  In this article
Abstract
Introduction
Patients and Methods
Results
Discussion
Conclusion
Acknowledgement
References
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