The Role of Oesophagogastroduodenoscopy in Avoiding Unnecessary Cholecystectomies in Patients with Gallstones and Upper Abdominal Discomfort

Background and objective: Cholelithiasis is a common condition, 10-20% of the population will develop gallstones, the incidence increases with age. Only about 30% of asymptomatic patients will warrant surgery during their lifetime.Dyspeptic symptoms due to other abdominal conditions such as PUD, IBS, Functional dyspepsia, IBS& GERD are frequently attributed to Gallstones. The current study aimed to asses the role of upper endoscopy in patients with gallstones in avoiding unnecessary cholecystectomies. Patients and methods: 124 patients were included in sulaimanyah city hospitals from october 2015 to february 2017 complaining of upper GIT symptoms and U/S evidence of gallstones and an oesophago-gastroduodenoscopy (OGD) is performed to exclude other possible explanation which may avoid unnecessary operation. Results: Among 124 patient 99 (79.8%) were females and 25 (20.2% ) were male, The mean age of studied patients was 46.4±14.5 years.The OGD findings of patients with Gallstones were normal 63 (50.8%), deudenal ulcer 24 (19.4%), non significant findings 24(19.4%), reflux esophagitis 10 (8.2%), gastrodudenitis 2 (1.6%)and fungal esophagitis 1 (0.8%) ,There was 12(9.6%) patients in whom surgery decision was changed while in 112(90.4%) the surgery was done. Conclusion: OGD is a very useful tool in the preoperative evaluation of patient with Gallstones with upper gastrointestinal tract (GIT) symptoms.


Introduction:
Gallstone is one of the commonest problems in GE practice. [1][2][3] The prevalence is 5-10% mostly among female & middle to elder age groups 4,-7 , rising in many countries including Iraq. 8 .In England 70000 & USA > 0.5 million cholecystectomies done each year. 9 Risk factors include ; advancing age , multiple pregnancies, obesity, repeated fluctuations in body weight, rapid weight loss >1.5 kg/week, high dose estrogens & Cholestyramine/fibrates. [10][11][12] Protective factors may include moderate exercise, coffee & moderate alcohol consumption. [13][14][15] Presentations of gallstones include asymptomatic & symptomatic ones which include: A. Biliary colic: a Moderate -Severe epigastric or right hypochondriac pain that last for 15 minutes to 6 hours or less than 24 hours , not associated with fever & can be associated with nausea / vomiting ,usually resolve spontaneously or by medications. 16

Patients and methods:
A prospective study in sulaimanyah govermental hospitals (KCGH,Shar teaching hospital & Surgical teaching hospital). A total number of 124 patients with U/S diagnosed GSs & upper GIT symptoms were referred to do OGD. A full history &clinical exam carried out with emphasis on upper GIT & Biliary symptoms. Patients were followed out to see in how many patients the decision to do operation was changed in the short term follow-up of our study period. Inclusion criteria: any adult with U/S evidence of GSs & upper GIT symptoms.
Exclusion criteria: any case of complicated Gallstone including common bile duct stones,acute cholecystitis, pancreatitis, cholangitis.
The change in decision for surgery was observed among 9.7% of patients with Gallstones after OGD. In 90.3% there had been no change in decision (Figure 4).
There was a significant association (P= 0.02) between patients detected with duodenal ulcer by OGD & decision change (Table 1).
There was a significant association (P= 0.002) between Gallstone patients with abnormal OGD findings & decision change ( Figure 5).        Our patients were 124 in number, female 99 (79.8%) , 25 (20.2%) and a female to male ratio of 3.96/1 ,similar prevalence observed in a study carried out in India. [28][29][30][31][32][33] In our study the OGD findings of patients with upper GIT symptoms and Gallstone were normal 63 (50.8%), duodenal ulcer 24 (19.4%), non-significant findings 24(19.4%), reflux esophagitis 10 (8.2%), gastroduodenitis 2 (1.6%) and fungal esophagitis 1 (0.8%). The results were near to results of a study carried out by Thybusch et al in Germany, which showed 50% of patients had pathological findings on OGD examination. 34 Another study in Germany recommend that OGD must be done before an elective cholecystectomy &showed that out of 960 patients for elective cholecystectomy, 589 underwent gastroscopy 56% had normal gastroscopy. 35 In our study the change in decision for surgery was observed among 9.7% of patients with upper GIT symptoms and Gallstones after OGD while 90.3% of them had no change in decision &underwent operation.The results of OGD findings changed decision in the management plan in 8.3% and 11.7% of patients in previously mentioned study by Thybusch et al. and Rassek et al., respectively. 34,35 A study in Poland showed that pathological findings were identified in 1187(42%) patients & the surgery was delayed for patients with ulcers until they finished their medical treatment , sixteen patients had complete resolution of symptoms after medical treatment therefore cholecystectomy was not performed. 36 In a study done in Sudan included 108 patients with gallstones & OGD was done revealed different pathological findings in 61 (56%) , Cholecystectomy was done for 82 (76%) & 26 were treated conservatively. 37 A study in India showed that in 89 patients the management plan had to be changed in 7.9% of patients based on the upper GI endoscopy findings (P value <0.001). 38 In a meta-analysis of 12 cohort studies a total of 6317 patients with cholelithiasis underwent OGD & in 36.3% abnormality was found in OGD but only 3.8% of patient surgery was avoided. 39 Another study by Yavorski et al., recommend that patients who present with cholelithiasis &atypical abdominal pain undergo preoperative OGD, as they found that at least 9 per cent of the patients in their study had significant findings that altered their management. 40 In a study in India in 2016 , 216 patients with Gallstone underwent OGD, showed 100% who underwent LC, had relief of symptoms in patients with normal OGD finding while those with significant OGD findings either not went through surgery in 10(4.6%) or when surgery was done they had more gradual relief of symptoms in 6 months follow-up. 41 A study in England suggested that OGD should be considered as a routine investigation before LC especially in those, who present with overlapping upper GI symptoms. 42

Conclusions:
1.Gallstones is frequently silent & upper GIT symptoms can be attributed to other pathologies in upper GIT.
2. OGD is a very useful tool which can be used in every case with Gallstone & upper GIT complains especially those with atypical symptoms.
3. OGD before elective cholecystectomy can help avoid unnecessary surgeries.
4. Biliary colic was the most important symptom that predicted negative OGDs & led to the decision of proceeding to surgery, so every effort should be done to take a good history of typical biliary colic in those patients.

Recommendations:
1.We recommend to evaluate patients with Gallstones very carefully to avoid doing un-necessary LC.
2.We highly recommend OGD as an appropriate evaluation of patients planned for elective cholecystectomies.