1.  Methods

Prospective observational multicentre study involving Tameside NHS Foundation Trust Hospital UK, Mallow General Hospital, Cork, Ireland Republic, Liaquat University of Medical & Health Sciences, Jamshoro Pakistan, Shaheed Mohtarama Benazir Bhutto Medical University & Chandka Medical College Larkana, Pakistan. From December 2014 to November 2016. All patients diagnosed with gallstones based on ultrasound abdomen and typical or atypical abdominal pain, irrespective of age and sex. All patients were subjected to Upper Gastrointestinal Endoscopy 24 to 48 hours before cholecystectomy biopsy were obtained for histopathology if required. The OGD examinations were performed by Gastroenterologists and GI surgeons. Where polyps were found, they were removed and assessed histopathologically. Scheduled cholecystectomy was postponed for three months when there were gastric or duodenal ulcers, gastric polyps, or inflammatory changes of gastric mucous membrane until histopathologic results were obtained and ulcers healed. The decision for cholecystectomy was made by the surgeons. The following preoperative parameters were recorded: age, sex, obesity, previous abdominal surgery, presentation with acute cholecystitis, pancreatitis or obstructive jaundice, ultrasonography detection of gallbladder wall thickening or gallbladder stones, and the presence of Common Bile Duct (CBD) stones. Clinical patterns of patient’s pain, endoscopic and pathologic findings as well as related comorbidities were obtained from the patient’s case notes. Endoscopic findings divided the problem into four main groups, normal, inflammation, ulcer, and others (polyps, varices etc.) whilst the pathological findings were defined as benign and malignant. Inclusion criteria: Symptomatic patients willing to participate in the study, ultrasound proven gallstones. Exclusion criteria: Those patients not keen, unfit for surgery, Pregnant ladies due to risk of foetal loss, CBD stone, obstructive jaundice, carcinoma of gall bladder, were excluded.

2.  Statistical Analysis

Data were analysed using the Statistical Package for Social Sciences (SPSS, version 17). Mean values were compared using the Student t test. Univariate analysis of categorical variables was performed by the chi-square test.

3.  Results

During this period, 433 patients. The female to male ratio 3.5:1 (337 versus 96), and the mean patient age was 45.10 ± 6.31 years (21 to 65 years) (Table 1, Figure 1). 266 (61.78%) atypical pain and 167 (38.21%) Patients were present with typical pain (Figure 2). Ultrasound revealed multiple stones 335(77.36%), single stone 98 (22.63%), impacted stone at the neck of gallbladder was found in 76 (17.55%) patients, Thick wall gallbladder was seen in 247 (57.04%) patients and contracted gallbladder 51 (11.77%) patients (Table 2, Figure 3). Pre-operative upper gastrointestinal endoscopy findings revealed gastritis in 108 (24.94%), gastric ulcer 55 (12.70%), duodenal ulcer in 44 (10.16%), GERD in 31 (7.15%), Esophagitis in 37 (8.54%) cases, polyps 21(4.84%) and carcinoma of stomach 9 (2.07%). (Table 3, Figure 4). In all patients with typical pain complete relief of symptoms were observed within 13 days post- operatively, out of 266(61.43%) cases with atypical pain had persistence of symptoms in 157 (59.02%) cases up to four months (Table 4)

4.  Discussion

Gallstone disease remains one of the most common medical problems leading to surgical intervention. 70 - 85% per cent of people with cholelithiasis are asymptomatic [7] or have nonspecific symptoms such as pain in their abdomen, stomach, back or shoulder, which may be misattributed to other conditions such as dyspepsia or general back ache. In most cases, asymptomatic gallstone is detected incidentally through imaging such as ultrasound or MRI as part of investigations for other conditions. For about 20% of people with cholelithiasis, the condition is symptomatic and can cause morbidity and complications (cholecystitis, cholangitis, obstructive jaundice, pancreatitis) that can be extremely painful and, in some cases, life threatening and needing emergency treatment as well as high costs of medical care. In the United States, Gallstone disease is the second most expensive digestive disease only surpassed by gastroesophageal reflux disease. Every year about 700,000 cholecystectomies are performed in the United States [8], and 190,000 patients with gallstone disease undergo surgery in Germany [9]. About 70,000 cholecystectomies are performed every year in the UK, with significant costs for the NHS. The health care costs of gallstone disease (~ 6.5 billion dollars/year) increased by 20% over the last three decades in the United States [10]. Gallstones found incidentally in the investigation of gastrointestinal symptoms may become falsely incriminated to explain pathology that arises outside the biliary tree [11]. There is variation within the NHS in how asymptomatic gallbladder stones are managed once they have been diagnosed. Some adults are offered treatment to prevent symptoms and complications developing.

Others are offered a watch-and-wait approach, and only have active treatment once the stones begin to cause symptoms. The differential diagnosis between symptomatic gallstones and inflammatory disorders of gastrointestinal tract is difficult due to the similar symptoms. Sosada et al. assayed 2,800 patients who were treated for symptomatic cholelithiasis. 2,325 of them were female and 475 were male patients in the study about 42 % of the patients had pathological changes during their esophagogastroduodenoscopy, in 37.18 % an inflammatory component was found [12]. In another retrospective study by Dimitriou et al. data of 766 patients was analysed. The patients underwent a preoperative esophagogastroduodenoscopy independently of their symptoms and they found inflammatory changes of the upper gastrointestinal tract in 43.1 % of their patients [13]. Sosada et al. also state that some patients still suffered from epigastric pain after a successful surgery, which might be due to an unrecognised inflammatory disease of the upper gastrointestinal tract. The diagnosis of a peptic ulcer led to a cancellation of the cholecystectomy and was replaced by PPI therapy because of the high risk for bleedings or perforation. Only after medical treatment some patients still underwent a cholecystectomy due to persisting epigastric pain. In helicobacter pylori -positive patients an additional treatment with antibiotics was necessary [12]. The study of Dimitriou et al. however did not show any significantly higher necessity to change a surgical treatment to a medical therapy in patients with atypical epigastric pain [13]. There are wide range of gastrointestinal symptoms have been linked to gallstones but causal relationship has not been established yet [1,3]. It is commonly accepted that removal of the gallbladder is the best treatment for symptomatic gallstone disease [14]. However, less focus has been on patient selection and typical or common symptoms of this disease to understand prevailing symptoms after surgery. Nevertheless, given the high proportion of non-specific abdominal symptoms in the people with known gallstones may lead to unjustifiable cholecystectomies [1,15].

There are a range of endoscopic, surgical and medical treatments available to treat gallstone disease. Surgery to remove the gallbladder (cholecystectomy) is the most common way to treat biliary pain or cholecystitis caused by gallstones and is one of the most commonly performed surgical procedures in the NHS. An upper GI endoscopy has been recommended in patients with nonspecific upper abdominal pain, history of peptic ulcer disease and persisting pain after laparoscopic cholecystectomy [4]. In our study Pre-operative upper gastrointestinal endoscopy findings revealed normal gastroscopy in 34.03% (130 out of 382 patients) this is in contrast with other studies. Rassek et al., in his study 589 out of 960 patients underwent gastroscopy for elective cholecystectomy, however 56% had normal gastroscopy, 11.3% (113 patients) underwent a change in plan of therapy because of the OGD findings, [16] and recommended that investigation of the upper gastrointestinal tract must precede an elective cholecystectomy. Schenk et al., in his study, 1064/ 1143 (93.1%) patients underwent OGD and 345 patients (30.2%) had pathological findings. Of these, 68.3% were inflammatory in nature 28 patients (2.5%) underwent additional GI surgical procedures along with cholecystectomy and bile duct exploration 19.8% (227 patients) underwent pharmacological treatment of the gastrointestinal disease after their biliary surgery [17], and suggested that owing to the high incidence of concurrent disease in the upper GI tract, preoperative gastroscopy should be performed prior to elective surgical therapy of symptomatic gallstones. Study of Thybusch et al. discuss the value and therapeutic implications of routine OGD before cholecystectomy, in his study 47.3% (160/338) patients undergoing cholecystectomy also had Upper GI endoscopy, amongst those he observed gastritis (25.7%), peptic ulcer disease (6.8%), hiatus hernia (4.7%) polyps (3.2%), oesophagitis (3%), gastric erosions (1.8%) and gastric cancer (.6%).

Findings on gastroscopy did not necessarily correlate with clinical symptoms. OGD findings influenced management in 8.3% of patients and the surgery was postponed awaiting medical treatment. Further, two patients with gastric cancer underwent gastrectomy [18]. In studies by Faisal et al and Mozafar et al found 77.2% and 83% of patents with atypical pain had abnormal OGD findings [19,20]. This establishes the importance of UGE prior to elective cholecystectomy especially with atypical pain. In our study, the diagnosis of peptic ulcer did not lead to a cancellation or the postponing of the cholecystectomy. They were treated simultaneously with PPI and in cases of helicobacter pylori-positive with triple therapy. The reproducibility of the study would be difficult due to the subjective selection of the results. In the case of more than one existing option, it was not possible to select all diagnoses. This could lead to the impression that some diagnoses are more frequent than others. In the present study, therapeutic approach was changed in 9 (2.35%) who were diagnosed with malignancy in pathological reports.

Prospective design of the study, it was possible to evaluate the symptoms of the participating patients. A potential weakness of study variation in practice in country (Asia and Europe), cost effectiveness of routine OGD for every patient. In author’s opinion, it would have been necessary to exclude patients with the clear diagnosis of a cholecystitis with ultrasound abdominal. An acute cholecystitis would almost always require surgical treatment, as it explains the symptoms. Higher incidence of concurrent upper gastrointestinal problems in patients with gall stones and atypical abdominal pain OGD before elective cholecystectomy can highly influence the management which in this group can be clinically helpful regarding postoperative outcomes. It would also have been necessary to follow up the patients subsequently

5.   Conclusion

We recommend Preoperative Gastroscopy in patients with nonspecific upper abdominal pain and history of peptic ulcer disease

Figure 1

Figure 2: 

Figure 3

Figure 4

Table 1: Demographics.

1. Schirmer BD, Winters KL, Edlich RF (2005) Cholelithiasis and cholecystitis. J Long Term Eff Med Implants 15: 329-338.
2. Stinton LM, Shaffer EA (2012) Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver 6: 172-187.
3. Kraag N, Thijs C, Knipschild P (1995) Dyspepsia-how noisy are gallstones? A meta-analysis of epidemiologic studies of biliary pain, dyspeptic symptoms, and food intolerance. Scand J Gastroenterol 30: 411-421.
4. Fahlke J, Ridwelski K, Manger T, Grote R, Lippert H (2001) Diagnostic workup before laparoscopic cholecystectomy-which diagnostic tools should be used?. Hepato gastroenterol 48: 59-65.
5. Ure BM, Troidl H, Spangenberger W, Lefering R, Dietrich A, et al. (1992) Evaluation of routine upper digestive tract endoscopy before laparoscopic cholecystectomy. Br J Surg 79: 1174-1177.
6. Al-Azawi D, Rayis A, Hehir DJ (2006) Esophagogastroduodenoscopy prior to laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 16: 593-597.
7. Sakorafas HG, Milingos D, Peros G (2007) Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy. Dig Dis Sci 52: 1313-1325.
8. No authors listed (1993) National Institutes of Health Consensus Development Conference Statement on gallstones and laparoscopic cholecystectomy. Am J Surg 165: 390-398.
9. Lammert F, Neubrand MW, Bittner R, Feussner H, Greiner L, et al. (2007) S3-guidelines for diagnosis and treatment of gallstones. German Society for Digestive and Metabolic Diseases and German Society for Surgery of the Alimentary Tract. Z Gastroenterol 45: 971-1001.
10. Everhart JE, Ruhl CE (2009) Burden of digestive diseases in the United States. Part III: liver, biliary tract and pancreas. Gastroenterology 136: 1134-1144.
11. Halldestam I, Kullman E, Borch K (2008) Defined indications for elective cholecystectomy for gallstone disease. Br J Surg 95: 620-626.
12. Sosada K, Zurawinski W, Piecuch J, Stepien T, Makarska J (2005) Gastroduodenoscopy: a routine examination of 2,800 patients before laparoscopic cholecystectomy. In: Surgical endoscopy 19: 1103-1108.
13. Dimitriou, Reckmann B, Nephuth O, Betzler M (2012) Stellenwert der routinemäßigen präoperativen Ösophagogastroduodenoskopie vor elektiver Cholezystektomie. IN. Zentralblatt für Chirurgie, 137: 38- 42.
14. Berger MY, Olde Hartman TC, Bohnen AM (2003) Abdominal symptoms: do they disappear after cholecystectomy? Surg Endosc 17: 1723-1728.
15. Glambek I, Arnesjo B, Soreide O (1989) Correlation between gallstones and abdominal symptoms in a random population. Results from a screening study. Scand J Gastro‐ enterol 24: 277-281.
16. Rassek D, Osswald J, Stock W (1988) Routine gastroscopy before cholecystectomy. Chirurg 59: 335-337.
17. Schwenk W, Bohm B, Badke A, Zarras K, Stock W (1992) Preoperative esophagogas- troduodenoscopy before elective surgical therapy of symptomatic cholelithiasis. Leber Magen Darm 22: 225-229.
18. Thybusch A, Schaube H, Schweizer E, Gollnick D, Grimm H (1996) Significant value and therapeutic implications of routine gastroscopy before cholecystectomy. J Chir (Paris) 133: 171-174.
19. Faisal A, Gadallah AN, Omar SA, Nagy MA (2013) The role of upper Gastrointestinal Endoscopy in Prevention of Post - Cholecystectomy pain prior to the elective surgical therapy of chronic cholecystitis. Med J Cairo Uni 81: 289-293.
20. Mozafer M, Sobhiyeh M, Heiba Tollahi M (2010) Is esophagogastroduodenoscopy essential prior to the elective surgical therapy of symptomatic cholelithiasis?. Gastro enteroscopy and Hepatology from bed to Bench 3: 77-82.