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Part IL a Clinical Study 148 W. S. Hwang Gut: first published as 10.1136/gut.11.2.148 on 1 February 1970. Downloaded from References Chou, S. T., and Gibson, J. B. (1968). Experimental cholangitis Leong, H. K. (1959). Opium addiction in Singapore. Dissertation and cholelithiasis. Brit. J. exp. Path., 49, 565-573. for Diploma in Public Health. London School of Hygiene Cleland, J. B. (1953). Gallstones in 7,000 postmortem exam- and Tropical Medicine. inations. Med. J. Aust., 2, 488-489. Lieber, M. M. (1952). The incidence of gallstones and their cor- Cobo, A., Hall, R. C., Torres, E., and Cuello, C. J. (1964). relation with other diseases. Ann. Surg., 135, 394-405. Intrahepatic calculi. Arch. Surg., 89, 936-941. Maki, T. (1961). Cholelithiasis in the Japanese. Arch. Surg., 82, Cook, J., Hou, P. C., Ho, H. C., and McFadzean, A. J. S. (1954). 599-612. Recurrent pyogenic cholangeitis. Brit. J. Surg., 42, 188-203. Muir, C. S. (1964). Demography and age-sex distribution of the Digby, K. H. (1930). Common-duct stones of liver origin. Brit. autopsy populations of multiracial Singapore. Singapore J. Surg., 17, 578-591. med. J., 5, 96-104. Dineen, P. (1964). The importance of the route of infection in Newman, H. F., and Northrup, J. D. (1959). The autopsy experimental biliarytract obstruction. Surg. Gynec. Obstet., incidence of gallstones. Int. Abstr. Surg., 109, 1-13. 119, 1001-1008. Ong, G. B. (1962). A study of recurrent pyogenic cholangitis. Flemma, R. J. F., Flint, L. M., Osterhout, S., and Shingleton, Arch. Surg., 84,199-225. W. W. (1967). Bacteriologic studies ofbiliarytract infection. Robertson, H. E. (1945). The preponderance of gallstones in Ann. Surg., 166, 563-572. women. Int. Abstr. Surg., 80, 1-23. Goodman, L. S., and Gilman, A. (1965). The Pharmacological Snapper, I. (1941). Chinese Lessons to Western Medicine. Inter- Basis of Therapeutics. 3rd Ed. Macmillan, New York. Science, New York. Gross, D. M. B. (1929). A statistical study ofcholelithiasis.J. Path. Stitnimankarn, T. (1960). The necropsy incidence of gallstones in Bact., 32, 503-526. Thailand. Amer. J. med. Sci., 240, 349-352. Harrison-Levy, A. (1962). The biliary obstruction syndrome ofthe Stock, F. E., and Fung, J. H. Y. (1962). Oriental cholangio- Chinese. Brit. J. Surg., 49, 674-685. hepatitis. Arch. Surg., 84, 409-412. Hur, K. B., Rice, R. G., and Hong, S. S. (1963). Cholelithiasis in Teoh, T. B. (1963). A study of gallstones and included worms in Koreans. Yonsei med. J., 4, 103-117. recurrent pyogenic cholargitis. J. path. Bact., 86, 123-129. Kozoll, D. D., Dwyer, G., and Meyer, K. A. (1959). Pathologic Torvik, A., and H0ivik, B. (1960). Gallstones in an autopsy series. correlation of gallstones. Arch. Surg., 79, 514-536. Acta chir. scand., 120, 168-174. Lam, K. L. (1967). Linctus codeine and opium poisonings in Wallnofer, H., and von Rottauscher, A. (1965). Chinese Folk Singapore children. J. Singapore paediat. Soc., 9, 101. Medicine. Crown Publishers, New York. Part IL A clinical study http://gut.bmj.com/ H. K. CHIAM, P. N. UNNI, AND W. S. HWANG on October 2, 2021 by guest. Protected copyright. From the Departments ofSurgery and ofPathology, Univ_rsity of Singapore, Singapore SUMMARY In the present study of 241 patients submitted for gallbladder and biliary tract surgery, it is found that choledocholithiasis in cases in Singapore presents with a wide spectrum of clinical manifestations. It is essential that the less common clinical presentations should be rzcognized. Recurrent pyogenic cholangitis, a syndrome in- has attracted much attention and there are frequently encountered elsewhere, is a major several reports on various aspects of this syn- biliary tract disease in the Orient. This entity drome (Cook, Hou, Ho, and McFadzean, 1954; 149 Cholelithiasis in Singapore. Part II A clinical study Gut: first published as 10.1136/gut.11.2.148 on 1 February 1970. Downloaded from Huang, 1959; Jessen, 1961; Maki, 1961; Ong, 2%. The Chinese and Malay populations show 1962; Stock and Fung, 1962). However, informa- a slight excess of males, but in the Indian and tion on the general pattern of biliary diseases in Pakistan population there is a twofold excess Oriental populations has been scanty and incom- of males (Singapore, Chief Statistician, 1959). plete, and for the number of individual reports The Singapore Government maintains a com- it is evident that such information is essential for prehensive medical service. Consultations and a better understanding of the nature and patho- treatment in government hospitals are mostly genesis of Oriental cholelithiasis. free; there are a few fee-paying wards where This paper presents an analysis of gallstone those having the means and senior government disease in a multiracial Oriental population and is officials may be admitted. It may be reasonably based on patients admitted to the Professorial assumed that the fee-paying patients are of a Surgical Unit, General Hospital, Singapore, from higher socio-economic group in Singapore. 1 August 1962 to 31 December 1966. Other forms of bias, such as types of patients admitted, hospital utilization rates of the various races, etc, have been more fully discussed else- where (Muir, 1962, 1963). Materials and Methods The clinical records of patients with biliary diseases were reviewed. Patients with neoplasia, Results trauma, or malformation of the biliary tract were excluded. There were 241 patients who had undergone Singapore has a multiracial population of surgery of the biliary tract for conditions other about 1.5 million people. Chinese are in the than neoplasia, trauma, and malformations of the majority, 75 % of the total; Malays form 14%, biliary tract. The lesions studied fell in three Indians and Pakistanis 9 %, and others, ie, main groups: (1) gallstones limited to the Europeans, Eurasians, Ceylonese, Arabs, etc, gallbladder (cholecystolithiasis without choledo- cholithiasis), 120 cases; (2) gallstones or biliary 'mud' in the bile ducts with or without similar involvement of the gallbladder (choledocho- Age Cholecysto- Choledocho ± lithiasis with or without cholecystolithiasis), lithiasis Cholecysto- http://gut.bmj.com/ lithiasis 109 cases; (3) cholecystitis without stones, 12 cases. Male Female Male Female The distribution of Chinese patients by race, 0-9 0 0 0 0 age, and sex is shown in Table I. 10-19 0 2 0 2 20-29 3 2 1 2 As the pattern of biliary disease differed among 30-39 7 8 5 9 the various races, a more detailed presentation 40-49 1 1 1 3 7 12 of the results is accordingly divided into major 50-59 20 10 19 7 on October 2, 2021 by guest. Protected copyright. 60-69 3 8 19 11 groups by race. 70-79 2 2 3 7 804- 0 2 0 0 Total 46 47 54 50 Biiary Tract Diseases in Chinese No. of paying 16 16 3 3 patients CHOLECYSTOLITHIASIS WITHOUT Table I Cholelithiasis in Chinese by sex, age, and CHOLEDOCHOLITHIASIS (93 CASES) site The male patients in the 50-59 age group out- numbered the female patients by 2 to 1. There were three male opium addicts in this age group. No. of Cases Born in China Paying Class Opium Addicts Significant findings in this group see also Table II Male Female Male Female Male Female Male Female are: the presence of 33 radiopaque stones detected Cholecystolithiasis by plain x-ray of the abdomen, and 19 cases of without pure pigment stones found at operation. choledocholithiasis 46 47 281 23 16' 163 6' 1 Choledocholithiasis Analysis ofthe Chinese series showed that these with/without 93 patients were made up of 82 'uncomplicated' cholecystlithiasis 54 50 471 31 3' 3' 23' 1 cases, six of empyema of the gallbladder, and one of cholecystoduodenal fistula with gallstone Table 11 Frequency of choledocho- with/without ileus. Of the six patients with empyema of the cholecystolithiasis related to sex, place of birth, gallbladder, four were opium addicts. paying ciass, and opium addiction. Four patients (two males, two females) died 'x' = 7-729, n = 1, p < 0-01. postoperatively. There was one male opium 'x' = 11-953, n = 1, p < 0.01. *X* = 7.779, n = 1, p < 0-01. addict. The causes of death were acute pan- 'x' = 9.149, n = 1, p < 0-01. creatititis, bronchopneumonia, myocardial in- 150 H. K. Chiam, P. N. Unni, and W. S. Hwang Gut: first published as 10.1136/gut.11.2.148 on 1 February 1970. Downloaded from farction, and paralytic ileus with acute dilatation China, and one an opium addict, and four of the stomach. females, one of them Chinese.1 None was an opium addict. Ages ranged from 7 to 80 years (7, 34, 63, 48, CHOLEDOCHOLITHIASIS WITH OR WITHOUT 50, 51, 55, 58, 62, 80). One woman and three CHOLECYSTOLITHIASIS (104 CASES) men were admitted to a fee-paying ward. The age, sex distribution of these cases, and their The clinical picture was that of acute chole- relationship with place of birth, type of ward cystitis but no stones were found in the gall- to which they were admitted, and addiction to bladder or the bile ducts. opium is shown in Table II. The male patients in the 50-69 age groups outnumbered the female patients by 2.1 to 1. There were 12 male addicts in the 50-69 age groups. Cholelithiasis in Other Races In 53 cases, discrete stones were present in both the gallbladder and the bile ducts. Gallstones m-ere limited to the bile ducts in 30 cases. The CHOLECYSTOLITHIASIS (27 CASES) remaining 21 cases had no formed stones, but The clinical symptoms and laboratory and other had biliary 'mud' and infected bile in the biliary findings resembled those of the Chinese patients. tract. Histological examination showed acute chole- cystitis or acute and chronic cholecystitis in 19 cases and chronic cholecystititis in 85 cases.
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