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Gallstones in Chronic Liver Disease

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Gallstones in Chronic Liver Disease Review Article Gallstones in Chronic Liver Disease 1\IlichaelAnthuny Silva, M.B.B.S., M.S., FR.CS.Ed, Terence Wong, M.B.B..','., Ph.D., 1H.R.C.P. Gallstones oeeur more eommonly in patients with eirrhosis. The ineidenee inereases with severity of liver discase, and the majority remain a~ymptomatie. \Vhen symptoms do oeeur, morbidity and mortality are mueh higher than in noneirrhotie patients. A~)'mptomatie gallstones in eirrhotie patients are best managed eonservatively with dose follow-up and surgery if ~ymptoms oeeur. The management of asymptomatie gallstones found ineidentally at abdominal surgery for another indieation is controversial. Laparoseopie eholeeysteetomy is the treatment of ehoiee for symptomatie eholelithiasis in patients with well-eompensated liver disease, whereas patients with eholedoeholithiasis are best managed endo- seopieally. Symptomatie eholclithiasis in the deeompensated patient remains a ehallenge, and these patients are best managed in speeialized hepatobiliary ecnters. This review examines the evidenee eurrently available on gallstones in ehronie liver disease and the factors that influence its management. (J G\STROI"'.I'FSTSURG2005;9:739-746) @ 2005 The Society for Surgery of the Alimentary Tract KEy \VORDS:Cholelithiasis, eholcdoeholithiasis, cirrhosis, ehoic<.ystectomy, cholecystostomy Gallstones (GS) are common in the general popu- a.lso co~firmed t~e hig~er prevalence of GS in pa- lation, and it is estimated that about 10-20% of the nents Wlth CLD,,6,8-IO:L.16(fable 1). adult population in developed countries have GS.I-3 These studies report the prevalence of asymptom- The prevalence is higher in women, the obese, and atic GS. The prevalence of c\inically manifest GS in older patients.I-3 The reported frequencies of GS in patients with CLO is largely unknown.17 A reeem chronic liver disease (CLD), in comparison, tends to retrospective review of medical records of 38,459 in- be higher.l-6 In autopsy studies, the frequency of GS patients with various forms of liver disease found in patients with CLD ranges from 3.6% to 46%, with the prevalence of symptomatic GS to be 7.5%,18 a 1.2- to 3-fold increasc comparcd with the general although the possibility of occasional detection bias population.I-3,7 Studies using ultrasonography report cannot be exc\uded. In a longitudinal cohort study of a group of 34 patients with asymptomatic GS and urevalence GS ranging between 22% and 54%.1.2, . ,8-11Oespite this high prevalence, the management CLO, 18% developed symptoms over 6 years.191\1- of GS in patients with CLD remains controversial, 1-4 though the number of patients in the study was and the aim of this review was to examine the evidence small and the duration of follow-up was short, this for current treatment strategies. figure is comparable to that of asymptomatic GS in noncirrhotic patients.1 In noncirrhotic patient~,there THE EPIDEMIOLOGY OF GALLSTONES is a mean delay of about 8 years between stone forma- IN PATIENTS WITH CHRONIC tion and the onset of symptoms.20 Ir is not clc.ir LIVER DISEASE whether this holds true for GS in CLO. There exists a 3:I female predominanec for the GS are found in 10-20% of the general adult popu- incidence of GS in the population without CLD.!.!,12 lation.I-3,12 In comparison, autopsy studies have This pattem is similar in patients with CLD,II,!I!' shown up to a threefold increase in GS among cir- although some early reports indica.ted that the inei- rhotic ~atients compared with noncirrhotic con- dence of GS was higher in males.) GS oceur more trolS.7,1,13,14Similarly, ultrasonographic studies have frequently in patients with cirrhosis than in paticllts From The Livcr Unit, QlIccn Elizabcth Hospital, University Hospital Birmingham NHS Trust, Edgbaston, Birmingham, Unitcd kingdom. Reprim reqllests: Michael A. Silva, M.S., F.R.C.S.Ed.. c/o Liver SlIrgical Secretaries, 3rd Floor, Nuftield House, Queen Elizaberh !lospir.]I, Univcrsity Hospital Birmingham NIIS Trust, Edgbaston. Birmingham BIS 2TII, United Kingdom. e-mail: [email protected] @ 2005 The Society tor Surgcry of the Alimemary Tract 1091-255X105/$- see tTom mancr Published by Elsevier lnc. doi: 10.10 16/j.gassur.2004.09.041 106 l Joumalof 740 Silvaand Wong Gastrointestinal Surgery Table 1. Prevalence of gallstones in chronic liver disease (CLO) Author (first) Year Type of study No. of subjects Prevalence of gallstones (%) Bouchier IAD7 1969 Autopsy Patients with CLD (n = 235) 29.4 Contrais (n = 4460) 12.8 Iber FLIO 1977 Autopsy Paticnts with CLD (n = 460) 33 Contrais (n = 316) 13 Iber FUo 1990 Autopsy Patients with CLD (n = 299) 46 Contrais (n = 178) 21 Fornari F5 1990 Ultrasound Patients with CLD (n = 410) 31.9 ContraIs (n = 414) 20 with chronic hepatitis,9 and pigment stones occur gallbladder disease. 17Male gender and alcoholic cir- more frequently in GS of patients with CLD, while rhosis have interestingly been found to have an in- its incidence also increases with age.8,15.24,25 verse relationship to the presence of symptoms.17 MECHANISMS OF GALLSTONE GALLSTONES IN RELATION TO FORMATION IN CHRONIC LIVER ETIOLOGY AND SEVERITY OF LIVER DISEASE DISEASE The mechanisms leading to the increased inci- dence ofGS in CLD are notwell understood.18 About The risk of GS appears to be indep.endent of the underlying etiology of liver disease.4. 5,26ln a study 80% of GS in patients with CLD are pigmem looking at the etiology of CLD, in 313 cirrhotic pa- stones compared with 20% in noncirrhotic pa- tiems, its cause did not seem to be importam as a risk tients.17,18.21;25.36Patiems with liver cirrhosis may also factor for GS formation.26 In another study of the have increased hemolysis secondary to hypersplen- prevalence of GS in CLO in relation to the etiology ism, resulting in a higher incidence of pigmem of disease, 356 cirrhotic patients were compared with stones.4.10 Studies have shown that however effi- 247 cases of chronic hepatitis B and C without cirrho- ciem, the liver does not convert ali the unconjugated sisj a multivariate analysis showed that the duration bilirubin into bilirubin monoglucuronides and diglu- and severity of cirrhosis were the only factors inde- curonides: a small fraction of the unconjugated pendently related to the development of GS in CLD, moiety escapes conjugation and 'spills' imobile.37 In whereas hepatitis B surface anti~en (HBsAg) positi- CLO, the fraction of bilirubin escaping conjuga- vity behaved as a negative factor. Several other stud- tion increases. The resultam excess unconjugated bi- ies have confirmed that the risk of developing GS is lirubin in bile is vulnerable to polymerization and/ correlated with severity of CLD as graded by the 01' to co-precipitation with free ionized calcium.37.38 Childs-Pugh classification, rather than the etiology Deconjugation may also be catalyzed by glucuroni- of the disease.5.6.8.9.18.21 dases of bacterial 01'mucosal origin,39 and bilirubin The etioloR of symptoms in patients with GS monoglucuronide may also undergo nonenzymatic is unknown.2 It may be partly due to chance, de- hydrolysis to form unconjugated bilirubin. Even in pending on the movement of stones and their im- normal bile, therefore, tlle low concentration of paction in Hartmann's pouch 01'in the cystic duct.1 unconjugated bilirubin still exceeds its aqueous 5011.1- It follows that the relative size of the calculi and bility by 100- to 1000-fold.39.4oThis unconjugated the caliber of various parts of the biliary tree may be bilirubin has been identified as a component ofbiliary importam. 1 It is, however, cIear that other factors sludge, which is believed to precede GS, especially play a role. Stasis may precipitate symptoms and pigmem stones.39 Additionally, decreased apolipo- is considered particularly relevam in tlle etiology of protein A-I and A-II levels in advanced CLO have postoperative cholecystitis.28-30 Stasis to bile flow is also been implicated as cause for a higher incidence of increased in CLD and may be a cause for the in- GS in these patients.zz creased incidence of GS in these patients.31-35 Ad- Pigment GS could be either black 01'brown. Black vanced age, female gender, viraI etiology of cirrhosis, pigment stones, which commonly occur in the gall- family history of GS, and duration of GS disease are, bladder only, are small (approximately 3 mm) and however, factors that are associated witll symptomatic occur witll increased frequency in patiems with CLD 107 Vol. 9, No. 5 2005 Gallstones in Chronic Liver Disease 741 and in those with hemolytic disease.9,11,ISBrown pig- dysfunction have impaired autonomic function.31 Au- ment stones are found more often in the biliary tree tonomic neuropathy may therefore contribute to the than in the gallbladder. Brown stones are convention- formation of GS in patients with advanced cirrhosis, ally associated with bacterial infection and parasitic perhaps by imBairing gallbladder and sphincter of infestations like fascioliasis (caused by the liver fluke). Oddi motility. 2 Gallbladder disease has also been Recent studies have, however, shown that neither found to be increased in patients with CLO and coex- the color nor the chemical composition accurately istent autonomic neuropathy.32 predicts the presence or absence of gallbladder bacte- ria and diseases that cause brown pigment stones, like fascioliasis, which may result in CLD, in turn possibly resulting in the formation of black pig- CLINICAL DIAGNOSIS OF GALLSTONES ment stones.-H,42 IN PATIENTS WITH CHRONIC Studies have shown that moderate intake of alcohol LIVER DISEASE
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