Abstract

Introduction: Cholelithiasis forms approximately 98% of symptomatic gall bladder disease and affects 10% of population in developed countries. The incidence of gall stone in third world has been steadily increasing and this has been attributed to the westernization of dietary habits. Cholecystitis is common pathological condition that is frequently diagnosed in majority of patients who come to outpatient department with history of abdominal pain and dyspepsia. Cholecystectomy is usually indicated in symptomatic patients having cholelithiasis. Many times there are gastrointestinal symptoms which may be erroneously attributed to presence of gallstones found incidentally at ultrasound. Majority of such patients continue to have similar symptoms even after undergoing cholecystectomy. The post-operative continuation of symptoms attributed to cholelithiasis was such a common occurrence so as to compel some authors to observe that ‘cholecystectomy has little or no effect in curing the unpleasant symptoms of flatulent dyspepsia.

With these facts in mind we conducted a study consisting of patients with cholelithiasis who fulfilled the criteria as laid down for the study. The purpose of this study was to determine the pre-operative incidence of flatulent dyspepsia in patients with gallstones and the effect of cholecystectomy alone on these symptoms.

Aims and Objectives:

1.      To study age and sex wise distribution and clinical presentations of gall stone disease with dyspepsia.

2.      To find out necessity of oesphagogastroduodenoscopy prior to cholecystectomy.

3.      To find out the incidence of acid peptic disease in patient of cholelithiasis.

4.      To study relief of symptom after cholecystectomy in patient who had undergone preoperative oesphagogastroduodenoscopy.

5.      To study the effect of various addictions on acid peptic disease in post cholecystectomy patients.

Materials and Methods: A prospective study of 50 cases was carried out at public hospital Mumbai over a period of 2 years. 50 patient of documented gall bladder pathology with dyspepsia and open or laparoscopic cholecystectomy done on them were studied. The study was approved by institutional ethical committee. Patients above 20 years of age and presenting to a tertiary care center with sign and symptoms of cholelithiasis and calculus cholecystitis were included in the study oesphagogastroduodenoscopy was done pre and post cholecystectomy. Patients who have asymptomatic gall stones, pregnant females and immunocompromised and Patients having any other clinical abdominal pathology were excluded from the study.

A detailed history was taken in all patients. Detailed clinical examination was done. Patients were managed according to set protocol. Postoperative course in the ward with regards to drain if kept, and removal of sutures and presence of complication if any were noted. Data was analyzed using approved statistical methods. 

Results: Majority of patients suffering with gall stones were in the age group of 31 – 40 yrs (46%) followed by 41 – 50 yrs (26%). Females were predominantly affected with a M:F ratio of 1:6. Most common presenting complaints were found to be abdominal pain (100%); vomiting (20%), fever (12%) and h/o jaundice (6%). Abdominal tenderness was present in 10 (20%) patients. On ultrasound 43 (86%) patients had features of chronic calculus cholecystitis while 7 (14%) patients had acute calculus cholecystitis. Common bile duct was normal in majority of the patients (94%) while only 3 patients (6%) had a dilated common bile duct. All patients had undergone preoperative oesphagogastroduodenoscopy out of which 5 (10%) patients had gastritis and 3 (6%) patients had peptic ulcer. 42 (84%) patients had a normal oesphagogastroduo-denoscopy. All patients once again had undergone oesphagogastroduodenoscopy on postoperative day 15. The findings were normal in 37 (74%) patients while gastritis and peptic ulcers were seen in 10 (20%) and 3 (6%) patients respectively. 41 (82%) patients had got relived of pain post operatively whereas 37 (74%) patients got relieved of dyspepsia. In our study of 50 cases, 5 patients were addicted to smoking, alcohol or both. Pain relief and resolution of dyspepsia was suboptimal in patients addicted to smoking or alcohol. Pain relief was not achieved in 57% males and 11% females. Dyspepsia was relieved in 71% males and 18% females. As the age advances there were less chances of pain relief and resolution of dyspepsia. Abnormal preoperative or postoperative OGDscopy was associated with fewer chances of relief of pain and resolution of dyspepsia after cholecystectomy.  Finally in this study 30% patients were not relieved of their symptoms out of which 14% patients were having pain and dyspepsia, 12% and 4% patients were having dyspepsia and pain respectively.

Conclusion: Due to the high incidence of simultaneous disease of the upper gastrointestinal disease we believe that routine preoperative oesphagogastroduodenoscopy is indicated before elective surgical treatment of cholelithiasis.

Keywords: Cholelithiasis, Cholecystectomy, Dyspepsia, Pain relief.

Dr Nitin Borle

Assistant Professor K.B.Bhabha Municipal General Hospital, Bandra, Mumbai