Gallstone Disease More Prevalent in North India

Gallstone disease (cholelithiasis) has increasingly become a major cause of abdominal pain and discomfort in the developing world.  Its occurrence has been found to be high (7.4%) in the adult population in the cities of Chandigarh and New Delhi in North India, which is interestingly seven times more frequent than in south India.

Female vs Males
At one time considered to be a disease commonly afflicting the fat, fertile, flatulent, female of around forty years, it now also more often seen in the postpartum primipara, who was a pre-pregnancy contraceptive pill user. Meaning thereby, that there is a definite shift in the trend of gallstone disease from middle aged, fertile, over weight females to young asthenic females in their twenties. Gallstones are much more common in the female population (61%) as compared to males (39%). The age group most affected is 45–60 years (38.5%) among females, and above 60 years in males (20.8%). A relatively higher prevalence of 39% among males when compared to reports from past studies indicates a significant shift in the pattern of prevalence of gallstone disease.

Dietary factors
In a recent study conducted the factors that emerged significant to cause the formation of gallstones are inadequate physical activity, high waist hip ratio (truncal obesity) and excessive intake of saturated fats. High total fat intake of the polyunsaturated kind, especially of animal origin in diet, may lead to loss of bile acids in stools, decreasing the bile acid pool and promoting super-saturation of cholesterol in bile rendering it more prone to form stones in the gallbladder. Low fiber intake and high refined sugars were similarly associated with tendency to gallstone formation. Those who take a higher proportion of vegetable proteins have a lower incidence of gallstones.

Sachdeva S, Khan Z, Ansari MA, Khalique N, Anees A. Lifestyle and Gallstone Disease: Scope for Primary Prevention. Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine 2011;36(4):263-267. doi:10.4103/0970-0218.91327.

How do gallstone form?
Gallstones are either cholesterol gallstones (pure and mixed) or pigment stones (black or brown). Super-saturation of bile with cholesterol and stagnation of bile in the gallbladder are the two major causative factors which predispose to cholesterol gallstone formation. Mixed cholesterol gallstones are the commonest stones in adults and in adolescent girls. Pigment stones are more common in children. The composition of gallstones is also different in different parts India. In north and eastern India gallstones are predominantly cholesterol stones. The myth that seeds in vegetables lead to gallstone formation needs to be dispelled. 

Do gallstones cause cancer?
The incidence of gallbladder cancer parallels the prevalence of gall stone disease; large and long-standing gall stones being associated with a higher risk of gallbladder cancer. Gall stone disease is common in north India and occurs at a younger age than in the western populations. Moreover, patients with gall stone disease present for treatment a long time after the onset of symptoms. Both these factors result in prolonged exposure of the gallbladder to stones. Besides gall stone disease, various other factors may also play a role in the causation of gallbladder cancer which is a North Indian disease.

Symptoms of gallstone disease

Asymptomatic Gallstones:
Most do not develop symptoms even after follow up periods as long as 20 years. Approximately 20% of patients develop symptoms by 15 years. Asymptomatic gallstone disease does not need surgery but there are important exceptions tabulated below.

1. High risk for gallbladder cancer

• North Indian women with gallstones
• Gallstones larger than 3 cm in diameter
• Porcelain gallbladder (calcification in the wall)
• Gallbladder polyps larger than 12 mm
  
  Note: The role of prophylactic cholecystectomy in young patients from various parts of India has been emphasized in many recent papers.
  

2. Diabetes

• Infection in the gallbladder in patients with gallstones can be life threatening
  

3. Lifestyle

• Working for prolonged periods in remote parts of the world with poor medical facilities
  
  

Symptomatic Gallstone Disease:

Although dyspepsia (upper abdominal fullness, flatulence or gas formation, heart burn, hyperacidity) are not considered typical symptoms of gallstones, in a study from AIIMS new Delhi of the 1,680 consecutive dyspeptic patients, 500 (29.8%) had gallstones. The common presentation of patients with gallstones is:

Biliary pain

:The typical first symptom is frequently characterized as pain in the right upper abdomen after a meal, more so after fatty foods.

Complications of gallstone disease

a. Acute Cholecystitis:

Often patients will have history of biliary pain which lasts for > 3 hours, associated with fever and right upper quadrant tenderness (Murphy’s sign).

b. Chronic Chlolecystitis:

Patients will have episodic epigastric or right upper abdominal pain lasting for more than 30 minutes

c. Choledocholithiasis:

When a stone from the gallbladder slips into the common bile duct it can lead to biliary colic, obstructive jaundice followed by acute cholangitis or pancreatitis.

d. Acute Cholangitis:

is a medical emergency. Patients may present with right upper quadrant abdominal pain, fever and jaundice. (Charcot’s triad)

e. Pancreatitis:

A most dreaded and life threatening complication of gallstones presents with very severe, persistent central upper abdominal pain, retching and prostration.

Diagnosis

The diagnosis can be made best by an upper abdominal ultrasound examination, carried out in the fasting state. In case the patient has jaundice or history of pancreatitis an MRI (MRCP) is required to confirm / exclude stones in the common bile duct before surgery is undertaken.