ORIGINAL RESEARCH PAPER Volume-8 | Issue-11 | November - 2019 | PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH

EVALUATION OF UGI SCOPY FINDINGS FOR PRE- ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY TO PREVENT POST CHOLECYSTECTOMY SYNDROME

General Surgery Dr. Ankush Misra Department Of General Surgery, Sree Balaji Medical College And Hospital, Chennai. Professer, Department Of General Surgery, Sree Balaji Medical College And Hospital, Dr. Sreedevi* Chennai. * Corresponding Author Professer, Department Of General Surgery, Sree Balaji Medical College And Hospital, Dr. Santhaseelan Chennai. Dr. Hema Department Of Medical Gastroenterology, Sree Balaji Medical College And Hospital, Vijayalakshmi V Chennai. ABSTRACT Background: Laparoscopic cholecystectomy is gold standard surgery for symptomatic gall stone disease which is the commonest disease needs surgical management. Symptomatology of the patients having upper GI pathologies can mimick the symptomatic gall stone disease and vice versa. Though biliary colic is specific for . Patients presenting with other gastrointestinal symptoms can also have gall stones. In this study UGI endoscopy was done for all patients with symptomatic and investigation proved gall stone disease to rule out other pathological causes of and prevent post cholecystectomy syndrome. Methods: Patients with Ultrasonography suggestive of single or multiple gall stones were included. Upper GI Scopy was done prior to laparoscopic cholecystectomy as per inclusion and exclusion criteria. All patients above 18years, with ultrasonographically proven diagnosis of cholelithiasis Results: In present study, 153 patients were included. Pain in abdomen was present in 88.2% of patients. Nausea/vomiting was second most common symptom and seen in 60.78%. It is also seen that OGD findings were abnormal in 108 patients (i.e.70.58%) and OGD findings were normal in 45 patients. The patients with abnormal ODG findings were subjected to pre op treatment of the respective GI pathology. Hence after Lap Cholecystectomy , post operatively patients were highly satisfied and relieved of their symptoms Conclusions: Cholecystectomy can be curative only whose symptoms are due to gallstones, and not due to other upper GI pathologies. Approach of performing OGD as a routine investigation prior to cholecystectomy, will decrease persistence of symptoms and prevent post-cholecystectomy syndrome. KEYWORDS Cholelithiasis, UGI Scopy INTRODUCTION commonly performed abdominal surgical procedure for cholelithiasis, Laparoscopic cholecystectomy is gold standard surgery for , acute , calcified gall bladder, symptomatic gall stone disease which is the commonest disease needs , choledocholithiasis etc. surgical management. It causes unnecessary burden of cost and surgical risk to patient, it also delays definitive treatment for the actual Some patients do not get symptomatic relief or get only partial relief cause.1 after laparoscopic cholecystectomy as symptoms are not entirely due to cholelithiasis. Symptomatology of upper GI diseases can be The pain due to the obstructing stone causes sudden expansion of the overlapping so upper gastrointestinal endoscopy is important to 2 gall bladder called “Biliary Colic”. This typical pattern of pain occurs identify the diseases of upper gastrointestinal tract as it evaluates the at right upper quadrant or epigastric region and lasts for 15 minutes to , stomach and along with direct visualization of several hours after a fatty meal. When pain gradually disappears, it the ampulla of Vater. It is considered a minimally invasive procedure usually leaves behind a dull ache with nausea and vomiting. As the and does not require any significant recovery after the procedure as it is supply is splanchnic nerve, pain radiates to right scapula or shoulder tip performed under local anesthesia in our institution. and occasionally to back. 80% of patients with cholelithiasis are 3-6 asymptomatic. Most studies show that patients appear to be Gallstones found incidentally in the investigation of gastrointestinal symptomatic at 2% to 3% yearly. Among them 2% have an overall risk symptoms may become falsely attributed to explain pathology that of biliary complications such as and acute arises outside the biliary tree.11 The majority of patients presenting with choledocholithiasis and 0.02% have the risk of incidence of upper abdominal pain undergo ultrasound examination and on cancer. Among symptomatic patients, 50% develop biliary detection of gallstones, the main focus of the attending clinician stays colic within a year. Though biliary colic is specific for gallstones, most around treating the gallstones and further investigations to rule out patients are present with other abdominal symptoms. other pathologies that may produce similar symptoms are not considered and surgery is often performed inappropriately. The term “symptomatic gallstones” is widely used to describe symptoms arising secondary to gallstones. The symptoms of gallstones are variable ranging from nonspecific to acute medical Persistent post cholecystectomy pain has been reported in a proportion emergency. Wide range of gastrointestinal symptoms that have been of patients called as “post cholecystectomy syndrome”. Post- linked to gallstones, but causal relationship has not been established. 7 cholecystectomy syndrome (PCS) consists of a group of abdominal symptoms that recur and/or persist after cholecystectomy. It is defined as early if occurring in the post-operative period and late if it manifests Symptoms that does not fit typical pain criteria is considered as 12 atypical and include any abdominal discomfort, dyspepsia, nausea, after months or years. Although this term is used widely, it is not belching, heart burn, food intolerance, flatulence, vomiting, loss of completely accurate, as it includes a large number of disorders, both appetite.8 Sometimes, patients have mixture of atypical upper GI biliary and extra-biliary in origin that may be unrelated to symptoms and discovered to have gallstones on imaging studies. The cholecystectomy. latter group are likely to be associated with poor symptomatic outcome. 9 Approach of performing OGD as a routine investigation prior to cholecystectomy, will decrease persistence of symptoms and will help It is commonly accepted that removal of the gallbladder is the best in detecting gastroduodenal pathologies at an early stage and prevent treatment for symptomatic gallstone disease.10 Cholecystectomy is a pcs. 58 International Journal of Scientific Research Volume-8 | Issue-11 | November - 2019 PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr

Many patients of upper gastrointestinal problems with gallstones have , , and hiatus may attribute to the post cholecystectomy syndrome.13,14

The challenge in the evaluation of patients with upper gastrointestinal symptoms, who also have gallstones, is to decide whether gallbladder stones are the source of the symptoms or an incidental finding and differentiating is important, as both conditions are common.

The persistence of abdominal symptoms after laparoscopic cholecystectomy patients is due to inadequate preoperative evaluation of other conditions that causes the same symptomatology. Thus, this Table 4 – Number of patients with normal/deranged Liver study was conducted to contribute UGI endoscopy as routine Function Test preoperative investigation and the importance of UGI endoscopy to NORMAL BILIRUBIN ABNORMAL BILIRUBIN evaluate the association between gastrointestinal symptoms with 114 39 gallstones and reduce the prevalence of post cholecystectomy pain. Table 5 - Ultrasonography findings for all the cases. METHODS FINDINGS NUMBER This prospective study is carried out in the department of general SOLITARY STONE 48 surgery in our institute. 153 patients attended to in surgical wards, MULTIPLE STONES 105 outpatient and emergency department were included. Patients presenting with complaints of right hypochondriac region, epigastric SIZE - <5mm 33 pain and with upper GI symptoms were assessed. All patients with 5-10mm 69 history suggestive of gall bladder diseases were evaluated and >10mm 51 investigated. Abdominal ultrasonography was performed at the time of THICKENED GB WALL 72 admission by well qualified, experienced radiologists. Patients with CBD ABNORMAL 9 ultrasonography suggestive of single or multiple gall stones were Table 6 - UGI Scopy Findings as observed by Gastro-Enterologist included and investigated. Upper GI scopy was done 1 to 2 days prior FINDINGS NUMBER to laparoscopic cholecystectomy as per inclusion and exclusion EROSIVE GASTRITIS 72 criteria. OESOPHAGITIS 15 ANTRAL EROSIONS 9 All patients above 18 years, with ultrasonographically proven CONGESTIVE GASTROPATHY 6 diagnosis of cholelithiasis and with symptoms (typical and atypical) were included. Patients not willing to provide written, informed LAX LES 2 content, patients below 18 years, patients with acute abdomen, whose CORPAL/FUNDAL EROSIONS 1 general conditions were not stable, cholangitis, gall stone pancreatitis, DUODENAL ULCER 1 cholecystoenteric fistula, gall bladder neoplasm, with past history of NORMAL STUDY 45 previous biliary/pancreatic surgery, refusing for surgery and/or upper gastrointestinal endoscopy were excluded.

Pre-operative data was reassessed. Informed written consent was taken with explanation of risk of conversion to open. Preoperatively nasogastric tube was placed. All patients received injection ceftriaxone 1gm intravenous during preoperative period. All patients were operated under general anesthesia.

ANALYSIS OF THE DATA Table 1. Number of patients in different age groups: AGE NUMBER Table 7 – Maximum and Minimum number of Post op days for 20-40 18 relieve of post operative pain in patients with normal OGD finding 40-60 25 vs patients with abnormal OGD findings >60 8 UGI SCOPY NORMAL UGI SCOPY ABNORMAL Max Post Op Min Post Op Max Post Op Min Post Op Pain relieve day Pain relieve day Pain relieve day Pain relieve day 1 month 1 week 2.5 mnths 1 week RESULT This study was carried out between July 2018 to june 2019. In this study, 153 patients of symptomatic cholelithiasis who had undergone diagnostic esophagogastroduodenoscopy prior to elective laparoscopic cholecystectomy were studied.

Chart 1. Number of patients in different age groups; The youngest patient was 21 years female and oldest was 70 years female. The mean age was 45.5 years. It is seen that cholelithiasis is Table 2 - Sex variation in Gallstone disease more common in females. The male: female ratio is 1:2.4 MALE FEMALE 45 108 In present study, pain in abdomen was present in 88.20% of patients. Nausea/vomiting was second most common symptom and seen in Table 3 – Number of patients having various complains at 60.78%. But the symptomatology was overlapping for individual presentation patients. It is also seen that abnormal OGD findings are seen in 108 SYMPTOMS NUMBER OF PATIENTS patients (i.e.70.58%). Out of 153 normal OGD was seen only in 45 EPIGASTRIC/RT HYPOCHONRIUM PAIN 135 patients. VOMITING 93 114/153 (74.50%) patients had normal LFT values including Serum FLATULENCE 33 bilirubin, AST, ALT and ALP. 18 ASYMPTOMATIC 18 Ultrasonographic findings for all the patients showed single (31.37%) DYSENTRY/ 4 or multiple (68.62%) stones in Gall Bladder of size <5mm in 21.56% International Journal of Scientific Research 59 Volume-8 | Issue-11 | November - 2019 PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr cases, 5-10mm in 45.09% of patients and >10mm in 33.33% cases. abdominal symptoms two years after a cholecystectomy. Gallbladder wall thickening seen in 47.05% patients and CBD abnormality in 5.88% cases. Symptoms occur in about 5 to 40 percent of patients who undergo cholecystectomy, and can be transient, persistent or lifelong. The OGD done for all the patients 1-3 days prior for elective surgery viz chronic condition is diagnosed in approximately 10% of Laparoscopic Cholecystectomy, which showed maximum number of postcholecystectomy cases. Erosive Gastritis (47.05%) in all OGD findings followed by Oesophagitis (9.80%). 29.41% of patients did not have any OGD The pain associated with postcholecystectomy syndrome is usually positive findings. ascribed to either sphincter of Oddi dysfunction or to post-surgical adhesions. A recent 2008 study shows that postcholecystectomy Patients with abnormal OGD findings, pre operative treatment was syndrome can be caused by biliary microlithiasis. Approximately 50% given for the respective pathologies. of cases are due to biliary causes such as remaining stone, biliary CONCLUSION injury, dysmotility and choledococyst. The remaining 50% are due to In this study, we have evaluated the different OGD pathologies the non-biliary causes. This is because upper abdominal pain and most common site of pathology was stomach (47.05%) that was gallstones are both common but are not always related. erosive gastritis. Followed by oesophagitis (9,80%). For inflammatory cause medical management was given. Non-biliary causes of PCS may be caused by a functional gastrointestinal disorder, such as functional dyspepsia. Symptomatology of the patients having upper GI pathologies can mimick the symptomatic gall stone disease and vice versa. Chronic diarrhea in postcholecystectomy syndrome is a type of bile Cholecystectomy can be curative only whose symptoms are due to acid diarrhea (type 3). gallstones, and not due to other upper GI pathologies. This can be treated with a - Approach of performing OGD as a routine investigation prior to bile acid sequestrant like cholestyramine, colestipol or cholecystectomy, will decrease persistence of symptoms and prevent colesevelam,which may be better tolerated. post-cholecystectomy syndrome. Symptoms of postcholecystectomy syndrome may include: DISCUSSION Ÿ Dyspepsia, nausea and vomiting. A gallstone is a stone formed within the gallbladderout of bile Ÿ Flatulence, bloating and diarrhea. components. The term cholelithiasismay refer to the presence of Ÿ Persistent pain in the upper right abdomen. gallstones or to the diseases caused by gallstones. Most people with gallstones (about 80%) never have symptoms. When a gallstone Some individuals may benefit from diet modification, such as a blocks the , a cramp-like pain in the right upper part of the reduced fat diet, following cholecystectomy. The liver produces bile abdomen, known as biliary colic (gallbladder attack) can result. This happens in 1–4% of those with gallstones each year. Complications of and the gallbladder acts as reservoir. From the gallbladder, bile enters gallstones may include inflammation of the gallbladder (cholecystitis), the intestine in individual portions. In the absence of a gallbladder, bile inflammation of the pancreas (pancreatitis), jaundice, and infection of enters the intestine constantly, but in small quantities. Thus, it may be a bile duct (cholangitis). Symptoms of these complications may insufficient for the digestion of fatty foods. Postcholecystectomy include pain of more than five hours duration, fever, yellowish skin, syndrome treatment depends on the identified violations that led to it. vomiting, dark urine, and pale stools. Typically, the patient is recommended a dietary restriction table with fatty foods, enzyme preparations, antispasmodics, and sometimes Risk factors for gallstones include birth control pills, pregnancy, a cholagogue. family history of gallstones, obesity, diabetes, , or rapid weight loss. The bile components that form gallstones include REFERENCES 1. Huang J, Chang CH, Wang JI, Kuo HK, Zin JW, Shan WY. Nationwide epidemiological cholesterol, bile salts, and bilirubin. Gallstones formed mainly from study of several gallstone disease in Taiwan. BMC Gastroenterol. 2009;9:63-65. cholesterol are termed cholesterol stones, and those mainly from 2. Basselink MGM, Erpecum KJ. 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Other complications include if there is a bacterial infection which can cause purulent inflammation in the biliary tree and liver, and acute pancreatitis as blockage of the bile ducts can prevent active enzymes being secreted into the bowel, instead damaging the pancreas. Rarely gallbladder cancer may occur as a complication.

Post cholecystectomy syndrome Postcholecystectomy syndrome (PCS) describes the presence of 60 International Journal of Scientific Research