Symptomatic Gallstone Disease and Associated Upper Gastrointestinal Pathologies-A Prospective Cohort Study

Abstract

Introduction: Gallstones Disease (GSD) is one of the common medical problems leading to surgical intervention. The gold standard treatment for cholelithiasis is cholecystectomy. Co-existence of concurrent Upper Gastrointestinal (UGI) problems in GSD patients have attributed to the Post-cholecystectomy Syndrome (PCS). PCS consists of a group of abdominal symptoms, that recur and/or persist after cholecystectomy. The associated upper Gastrointestinal (GI) pathologies are identified by UGI endoscopy. Helicobacter pylori (H.pylori) infection has been implicated in many GI and extra-GI diseases. This aspect of identifying associated pathologies in symptomatic gallstone disease and identifying H.pylori infection using gene-sequencing method has not been studied in Indian population. Aim: To study the associated UGI pathology detected by preoperative UGI endoscopy in symptomatic GSD and to compare the outcome based on the trend of PCS overtime. Materials and Methods: This prospective cohort study conducted in the Department of Surgery at Mahatma Gandhi Medical College and Research Insititute, Puducherry, India. The duration of the study was 18 months, from January 2019 to July 2020. The individuals over 18 years of age, who were symptomatic and ultrasonographically proven to have cholelithiasis formed the study group. The sample size was calculated to be N=50 (reduced to N=30 due to Coronavirus Disease-2019 (COVID19) pandemic). Patients underwent UGI endoscopy prior to surgery, to assess for associated pathology including H.pylori. They were followed at regular intervals postoperatively and assessed based on questionnaire for the occurrence of PCS. The quantitative and qualitative variables were summarised as frequency, percentage and Pearson’s Chi-square test and Fisher’s-exact test, respectively. The sensitivity and specificity of H.pylori positivity by Histopathological Evaluation (HPE) in biopsy samples was compared to Polymerase Chain Reaction (PCR) as the gold standard. The significance level was set at p-value<0.05. The trend of the symptoms was also studied overtime. Results: The mean age of the study population was 39.4±11.93 years. UGI abnormalities were present in 89.7% of the study group. H.pylori was identified in eight patients by histopathology examination while PCR detected 16 patients to have H.pylori. Sixteen out of 30 patients (53.3%) had PCS. It was also noted that, early PCS numbers tend to reduce over time, but the overall and late PCS numbers tend to increase over time. Although, a statistical analysis could not be performed, a graph was drawn to study the symptoms over the study period allowing observation of vital relation to gallstone disease. UGI pathology and H.pylori infection had a significant association with overall PCS with p-value=0.022 and 0.026, respectively. Conclusion: The present study recommends the use of preoperative UGI endoscopy in symptomatic GSD. The identification of H.pylori by PCR using population-based genesequences has a role in treatment of gallstone disease. The trend shows difference in behaviour of PCS overtime.