Is there any Change in Demographic Pattern of Patients with Cholelithiasis?

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1 ORIGINAL ARTICLE Is ere any Change in Demographic Pattern of Patients wi Choleliiasis? 2 3 Wasim Ahmed, Muhammad Iqbal, Ishtiaq Ahmed ABSTRACT OBJECTIVE: To see any change in demographic pattern among patients wi gallstone disease in our setup. STUDY DESIGN: A Descriptive analytic study. PLACE AND DURATION: Department of Surgery at Al-Nafees Medical College Hospital, Islamabad from 7 July 206 to 6 August 206. METHODOLOGY: The study includes all e patients presented wi gallstone disease in Surgery OPD. A specially designed questionnaire was used for collection of data which include biographic profile, Clinical presentation, duration of symptoms, associated illness, family history, previous surgical history, contraception history, and dietary habits of e patients. All e data was analyzed statistically to see any change in demography of e patients wi Gall stone disease. RESULTS: Female are almost two times more susceptible to have gallstone disease as compare to male i.e. 67.3% and 32.69% respectively. Patients wi Increasing age, height, BMI and positive family history have more chances of gallstones. Patients suffering from chronic illness (84.6%) and ose who have underwent major surgery (40.38%) in eir past also have increased risk to develop Choleliiasis. Patients consuming diet rich in lipids and carbohydrates (38.46%) were also higher wi gallstones. CONCLUSION: There is a notable change in demographic pattern of our patients wi gallstone disease as compare to e literature, which needs furer studies. KEY WORDS: Demographic Variables, gall stones, diet, BMI, age, Risk Factors HOW TO CITE THIS: Ahmed W, Iqbal M, Ahmed I. Is ere any change in demographic pattern of patients wi Choleliiasis? Isra Med J. 207;9(2):75-79 This is an Open Access article distributed under e terms of e Creative Commons Attribution-Non Commercial 4.0 International License ( which permits unrestricted use, distribution, and reproduction in any medium, provided e original work is properly cited. INTRODUCTION The great physician Alexander Trallianus has first described e Gallstones and he reported e calculi wiin e bile duct. By e 6 century, e Fallopius and Vesalius have reported e gall stones found in e gall bladder of a human body during dissection. 2 Gallstone disease is a worldwide medical problem wi geographical, racial and enic variations and ere is less 3,4 prevalence reported in Africans. There prevalence is 3 to 4 times higher among e female and it increases as age advance. Gall stones are rare before 20 year of age and frequency increase 2,3 as age advances in bo sex. In Asian countries, e prevalence of gallstone disease ranges from 3% to 0%. Incidence of Gall stone is increasing worldwide and during last fifty years its prevalence has doubled in Japan and change in prevalence from. House Officer Benazir Bhutto Hospital, Rawalpindi 2. House Officer 3. Professor of Surgery Al-Nafees Medical College & Hospital, Isra University Islamabad Campus Pakistan Correspondence to: Wasim Ahmed House Officer Benazir Bhutto Hospital, Rawalpindi malik_wasim25@yahoo.com Received for Publication: Accepted for Publication: ,3,5 pigment to cholesterol gall stone has also reported. Similarly, e high prevalence of gallstone disease is also observed in Native American Indians (Pima) in Arizona which is 73% in Pima 6 women around e age of irty. Clinically, e prevalence of gallstone in Asia has increased in last decade which is coincident wi e increased calorie and fat consumption, decreased dietary fiber intake and increase prevalence of e sedentary 7,8 lifestyle in e Asian population. Accoing to recent studies, e prevalence of gallstone disease in Japan was 3.2% in China0.7%, Norern India 7.%, and in Taiwan 5.0%. Clinically about 2/3 of e Patients wi gall stone remain undiagnosed because ey remained asymptomatic,2 roughout eir life. Symptoms of gallstones vary from patient to patient and if occurs it could range from abdominal discomfort to biliary colic and jaundice. When e gallbladder wi stones gets inflamed, an it can lead to pain, infection and 2 serious complications Many studies in literature shows at e gall stone disease has strong relation to multiple factors like age, sex, BMI, parity, diet and metabolic disoers such as diabetes, hyperlipidemia along 3,5, wi socioeconomic status. In past, e Gallstone disease 2,3 was considered a disease of e West but due to variation in above mentioned factors, e prevalence of gallstone disease is high in western or developed countries as compared to East 3,4 Asian countries. Due to change in socioeconomic factors and life style modifications, e prevalence of gallstone disease in East Asia is now almost similar to west. Studies has now explain better about e important modifiable risk and non-modifiable risk factors in gallstone paogenesis 2,3. In Pakistan, we are 75

2 beginning to have an increase frequency of gallbladder disease probably due to changing dietary habits i.e. increase calories, cholesterol and fats intake of e population. To furer evaluate is, a high index of suspicion and careful clinical judgment coupled wi e use of simple ancillary investigation like ultrasound will give an idea of is change in demographic pattern of gallstone disease. In our setup we had observed at e symptoms of e patients presented wi gallstones disease vary from one patient to anoer and eir demographic pattern like age, socioeconomic profile, parity and diet profile also vary from one to anoer. To evaluate it in a systematic way and due to limitation non availability of national data on demographic factors and presentation of gallstones we have planned to conduct is study on patients presented wi gall stone disease to see any changes in demographic pattern among patient. METHODOLOGY This descriptive analytic study was carried out in e Surgical Department of Al-Nafees Medical College Hospital, Islamabad from 7 June, 206 to 6 August, 206 in which all e patients reporting to clinic or admitted wi Choleliiasis were included. The approval for is study was taken from Institutional Review Boa Committee (IRBC), Al-Nafees Medical College and Informed consent was taken from e patients before including em in is study. All patients wi diagnosed gallstone disease on Ultrasound scan abdomen or on CT scan abdomen were included in e study. A predesigned structured questionnaire was used for collection of data in which hospital ID, age, gender, marital status, parity, occupation, income, education, residence, body mass index, clinical presentation, duration of symptoms, associated illness, family history, previous surgical history, contraception history, and diet history were recoded. Patients wi incomplete information's or not willing were excluded from e study. All data was collected by final year MBBS students by asking direct close ended questions or on examination. Data was analyzed in which association of all variable wi gall stone disease were analyzed and compared wi national and international literature to see any change. For statistical analysis all data was analyzed on SPSS version 20 in which frequencies and percentages were used and confidence interval was calculated of each variable. RESULTS A total of 52 patients were studied during e study period. Among em 7 (32.69%) were male and 35 (67.3%) patients were females. Majority of e patients were from 5 decade (n=23, 44.24%) followed by 3 decade (n=0, 9.30%) of life (Table I). Among em majority were married 3 (59.6%) followed by Single 4 (26.95%). Regaing educational status, about 7 (32.69%) were metric and 5 (28.84%) were having primary qualification. Among all patients, majority were house wife i.e. 28 (53.84%) followed by employees (Govt/Private) i.e. 4 (26.43%), 05 (9.62%) were doing business and only 04 (7.69%) were students. Most of e participants (n=22, 42.30%) were having income of rupees/mon followed by income of more an Rs /mon (n=3, 25.0%). Majority of em were living in rural areas (n=34, 65.38%). Regaing BMI of patients, majority of em were overweight (BMI kg/m ) or obese ( kg/m ) i.e. 24 (46.5%) and 5 (28.84%) respectively (Table II). TABLE I: SHOWS THE AGE AND GENDER DISTRIBUTION OF PATIENTS WITH GALLSTONE DISEASE (N=52) TABLE II: SHOWS THE FREQUENCY OF DIFFERENT DEMOGRAPHIC FACTORS OF PATIENTS WITH GALLSTONE DISEASE (N=52) 76

3 Table III shows e clinical presentation of e patients. Pain is e commonest symptom (n=43, 82.69%), followed by vomiting and fat intolerance (n=30, 57.69% each), nausea and indigestion (n=22, 42.30% each), bloating (n=5, 28.84%) and dyspepsia (n=3, 25%). Regaing duration of symptoms majority of patients (n=30, 57.69%) had symptoms from less an six mons followed by (n=2, 23.0%) wi less an one year and (n=0, 9.23%) had symptoms greater an one year. When we inquired about any previous surgical history, (n=2, 40.38%) patients had surgery in eir past. Regaing any associated illness, (n=5, 28.84%) were diabetic, (n=9, 7.30%) were hypertensive, (n=6,.53%) have caiac disease and (n=4, 26.9%) were suffering from liver disease. Among all participants in e study, (n=32, 6.53%) have positive response when inquired about history of gallstones in eir family. Among female, (n=6,.53%) have used oral contraceptive in past. About diet, majority of participants (n=8, 34.62%) were using dairy and meat products regularly during last ten years and (n=20, 38.46%) were in habit of using junk food and fatty food routinely. Only (n=4, 26.92%) were in habit of using more fruits and vegetables in eir diet (Table IV). TABLE IV: SHOWS PAST HISTORY, CO-MORBIDITY AND DIETARY HABITS OF PATIENTS WITH GALLSTONE DISEASE (N=52) TABLE III: SHOWS THE FREQUENCY AND DURATION OF SYMPTOMS OF PATIENTS WITH GALLSTONE DISEASE (N=52) DISCUSSION A study conducted by Jorgensen over Danish population shows at e prevalence of gallstones is almost 4 times higher in female during 3, 4 decade which reduced to almost twice higher in female after 4 decade group. The prevalence in 3 decade is.8% and 4.8% in male and female respectively which 4 rises up to 2.9% in male and 22.4% in female 6 decade of life.,3,2 Oer studied also shows almost e same results. In India e prevalence of gall stone disease is increasing progressively to reach a peak in e six decade. Gallstones are rare below 20 years of age and prevalence increase from 3 to 5 decade i.e. 4% in 3 decade to 27% in 7 decade among bo sexes. 3 Similar trend is also reported by Njeze in his meta-analysis. Our study shows at about 20% of e patients are in 3 decade of life which is quite high as compared to 3 decade gallstone frequency reported in literature. Highest frequency of gall stone disease is found in 5 decade in our study i.e % which is again high as compared to frequency reported in oer parts of e world. Studies shows at in all populations, regaless of overall gallstone prevalence, female are almost double at risk of developing gallstones during eir fertile years but is preponderance become less during postmenopausal period i.e. 3,4,22 wi increasing age is gender difference gets narrow. Fertile and multiparous women are affected more commonly en e non-fertile women. The female wi multiple pregnancies and longer fertility periods reported to have a more 3,8,5 likelihood of having gall stones as compared to nulliparous. About 67.3% of female were reported wi gallstone disease as compared to 32.69% of male in our study which is 2: ratio. In contrary e literature has reported female to male ratio is 4: 2,5 or 3:. After comparing wi literature, e frequency of male is quite high (32.69%) in our study which is quite alarming and needs to be studied furer. Among e female, most of em (59.62%) were married and only few of em (.53%) have used contraceptive in past. Whereas e literature reports oral contraceptives is one of e risk factor in gallstone paogens. Whereas majority of (88.47%) females in our study has not used oral contraceptives. Obesity is anoer important risk factor for gallstone especially cholesterol stones, which is more so for female as compared to male. Different epidemiological studies have found at e risk of gallstones in obesity is strongest in young women, and 3,6,7 slimness is protective against gallstone formation. About 60% of patients wi gallstone were obese as observed by Ahmed et al in eir study. About 46.5% of our patients were overweight and 28.84% were obese. Among all patients, almost ¾ of our patients were eier obese or overweight which is again high frequency as compared to international,6,7 literature. Exposure to western diet, i.e., increase intake of refined carbohydrates, fatty food and reduced fiber content is a potent risk factor for gallstones formation. Calcium, Vitamin C and Coffee consumption seems to be inversely associated wi gallstone paogenesis as reported in literature 3,8,8,9. Majority 77

4 of our patients have bad dietary habits i.e % were using more dairy and meat products and 38.46% were using junk food and fatty food routinely. This shows at e dietary habits could be one of e predominant factors in is demographic change of gallstone diseases among our studied population. The exact association of socioeconomic status wi gallstones is controversial. It is however, may be an indirect marker for oer 6,7,9 risk factors like obesity and chronic medical conditions. Studies have proved at e reduced physical activity increases e risk of gallstone disease whereas increased physical activity helps to prevent e choleliiasis, independent of its role in 9,20 weight loss. Most of e participants in our study who presented wi gallstone disease belong to rural areas (65.38%) and have low socioeconomic background (5.93%). Genetic susceptibility is a key factor in gallstone formation. Familial studies reveal an increased frequency wi a nearly five times increased risk in e relatives of patients wi gallstone. These rate are even higher in monozygotic twins at 2% and 4,20,2 dizygotic twins at 6%. Bo autopsy and population based studies clearly prove e existence of racial differences which cannot completely be explained by different environmental or demographic factors. The prevalence of cholesterol stone varies widely, from extremely low (<5%) in Africans and Asian population, to intermediate (0-30%) in Norern American and European peoples, to extremely high (30-70%) among Native American ancestry i.e. Pima Indians in Arizona, Mapuche Indians in Chile). More an 70% of Pima women more an 25 2,3,6,6 years of age had gallstones or a history of cholecystectomy. High prevalence of gallstone have also reported in oer Nor American Indian tribes, including e Chippewas, Navajo, 2,20 Micmacs, and Cree-Ojibwas. Ahmed and colleagues also reported strong family history in his study population. In our study, about 6.53% of e patients gave history of gall stone among eir family members or first relatives in family. Frequency of is association is again high in our studied population as compared to literature. The diabetics generally have high levels of triglycerides in blood which may increase e risk of gallstones. In addition, e Gallbladder function is also impaired in patients wi diabetic neuropay, and hyperglycemia regulation wi insulin 2 considered to raise e liogenic index. Different studies shows higher prevalence of gall stones in diabetics, chronic liver,3,5,22 disease. About 28.84% of e patients in our study were diabetic and 26.92% have liver disease. Most patients wi gallstones usually have no symptoms and ese gallstones are called silent stones which may not require treatment. The symptomatic stones commonly present wi recurrent episodes of right-upper-quadrant or epigastric pain which is probably due to impaction of stone in cystic duct. This may cause nausea and vomiting or dyspeptic symptoms. A patient may also experience intolerance to fatty food and often, e attacks typically occurs after a fatty meal and almost always,2 happen at mid night. Pain is e dominant symptom in 82.69% of patients in our study. Oer commonest symptoms were vomiting, fat intolerance indigestion and nausea. Almost 40.38% of e patients in our study had history of previous surgery in eir past and among em C-section is e commonest (7.30%) in female. Previous surgery may be associated wi gallstone but it is not yet proved in literature. Epidemiological studies have showed a marked variation in prevalence between different populations. Gallstone is e disease which is less prevalent in developed nations, but it is more prevalent in e developing populations at mostly 3 consume traditional diets. In our study it was noticed at most of e patients wi gall stones were males 29(58%).e age group in which most of e patient's presents to our study setup was 4 to 60 years which shows at prevalence and males are now equal or more prone to have Choleliiasis. CONCLUSION There is a notable change in demographic pattern of our patients wi gallstone disease as compare to e literature, which needs furer studies. Limitation of Study: This is a small scale and single center study, which needs furer multi-center large scale studies. Contribution of Auor: Ahmed W: Designed Research Study, Data Collection, Statistical Analysis, Manuscript Writing, Literature Review. Iqbal M: Data Collection, Statistical Analysis, Literature Review Ahmed I: Conceived e Idea, Manuscript Final Reading and Approval Disclaimer: None. 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