Is It Necessary to Perform Pre Operative Upper Gastrointestinal Endoscopy in Elective Symptomatic Cholelithasis?

Objective: Is it necessary to perform pre operative upper gastrointestinal endoscopy in elective symptomatic cholelithasis? Study Design: Prospective observational study. Place and Duration of Study: This study was conducted at surgical departments of Services Hospital, Ruth PFAHU, Civil Hospital Karachi, Shaheed Benazir Bhutto Medical College, Lyari Karachi and Liaquat University Of Medical and Health Sciences, Jamshoro from July 2018 to December 2019. Methodology: Study consisted of 382 patients. All patients were subjected to Upper Gastrointestinal Endoscopy 24 to 48 hours before cholecystectomy followed by biopsy were Original Research Article Shaikh et al.; JPRI, 33(40B): 13-17, 2021; Article no.JPRI.71560 14 obtained for histopathology if required. Those patients not willing for surgery, General anesthesia problem, pregnant ladies due to risk of foetal loss, carcinoma of gall bladder, stone in CBD and obstructive jaundice were excluded. Results: Out of the 382 patients, 66(17.27%) males and 316(82.72%) females with mean age of study population was 46.10 ± 6.31 years (22 to 65 years). Patients were present typical pain in 146(38.21%) cases and atypical pain in 236(61.78%) cases. Pre operative upper gastrointestinal endoscopy findings revealed Esophagitis in 22(5.75%) cases, GERD in 26(6.80%) cases, gastritis in 88(23.03%), gastric ulcer 49(12.82%), duodenal ulcer in 39(10.20%), polps 21(5.49%) and carcinoma of stomach 9(2.35%). Out of 236(61.78%) cases with atypical pain had persistence of symptoms in 141 (59.74%) cases upto four months. Conclusion: We conclude that upper gastrointestinal endoscopy preoperatively for gallstone disease should be performed. So that preoperatively atypical symptoms are evaluate and taken care of, and patients is fully informed and also treated for associated conditions.


INTRODUCTION
Gall stones are a common adult problem but only 2-3% of patients turn symptomatic annually [1]. The usual symptoms of gall stone disease include severe mid epigastric pain radiating to the upper right quadrant lasting from 15 minutes to several hours. It may be followed by nausea and vomiting. Gall bladder disease may also present with atypical pain which manifests as abdominal discomfort, dyspepsia, flatulence, nausea, vomiting or loss of appetite [2]. Keeping in mind the risk factors associated with it, when patients present with typical or atypical pain physicians usually order abdominal ultrasound and liver function tests [3]. When gall stones are detected, all emphasis lies on treating gall stones putting behind any need for further investigations [4]. 6-34% of patients don't get relief in pain after cholecystectomy and present with what is known as post cholecystectomy syndrome [4,5]. This phrase is a misnomer as causes for post cholecystectomy syndrome may be biliary or unrelated to the biliary tract. Biliary causes include common bile duct stones, inflammatory strictures of papilla, lesion of cystic duct stump and organic pancreatobiliary or gastro-intestinal disorders. Pain may be related to psychosomatic or extra-intestinal manifestations [6]. Another cause for persistence of abdominal pain even after successful cholecystectomy may be related to the fact that gallstones might not be the reason of abdominal pain for which causes were evaluated. There may be some other pathology lying behind for which ultrasound was ordered and led to incidental finding of gall stones. Extrabiliary pathologies such as gastritis, oesophagitis, hiatus hernia, duodenitis, gastric and duodenal erosions and ulcers, gastric polyps may be present along with gall stones [7]. They may be responsible for causing epigastric pain but when gall stones are found on ultrasonography, the physician turns his mind on cholecystectomy as the procedure of choice. Laparoscopic cholecystectomy is a very safe and effective procedure with minimal post-operative complications therefore patients consent to surgery very easily. But often the symptoms are not relieved after successful laparoscopic cholecystectomy.
Post-cholecystectomy syndrome then haunts the patient as well as the physician requiring further workup to look for its cause. If upper gastro-intestinal endoscopy is added to first line investigations for patient with gall stones this could lead to a better management plan which could be beneficial for the patient clinically and economically.

MATERIALS AND METHODS
This study was conducted at surgical departments of Services Hospital, Ruth PFAHU, Civil Hospital Karachi, Shaheed Benazir Bhutto Medical College, Lyari Karachi and Liaquat University Of Medical and Health Sciences, Jamshoro from July 2018 to December 2019. Study consisted of 382 patients. All patients diagnosed case of gallstones on the basis of ultrasound abdomen, irrespective of age and sex. Detailed Clinical examination regarding palpable mass, visceromegaly in the right hypochondrium and assessment of murphy's sign. All patients were subjected to Upper Gastrointestinal Endoscopy 24 to 48 hours before cholecystectomy followed by biopsy were obtained for histopathology if required. Those patients not willing for surgery, General anesthesia problem, pregnant ladies due to risk of foetal loss, carcinoma of gall bladder, stone in CBD and obstructive jaundice were excluded. Data analyses were using Statistical Package for Social Science (SPSS) software, Version 22.

RESULTS
Out of the 382 patients, 66(17.27%) males and 316(82.72%) females with mean age of study population was 46.10 ± 6.31 years (22 to 65 years). Patients were present typical pain in 146(38.21%) cases and atypical pain in 236(61.78%) cases. Ultrasound findings revealed was single stone in 83(21.72%) patients and multiple stones in 299(78.27%) patients, Impacted stone at the neck of gallbladder was found in 68(17.80%) patients, Thick wall gallbladder was seen in 221(57.85%) patients and contracted gallbladder 44(11.51%) patients (Table 1). Pre operative upper gastrointestinal endoscopy findings revealed Esophagitis in 22(5.75%) cases, GERD in 26(6.80%) cases, gastritis in 88(23.03%), gastric ulcer 49(12.82%), duodenal ulcer in 39(10.20%), polps 21(5.49%) and carcinoma of stomach 9(2.35%) (Fig. 1). In all patients with typical pain complete relief of symptoms were observed within 15days postoperatively. Out of 236(61.78%) cases with atypical pain had persistence of symptoms in 141(59.74%) cases upto four months. Upper gastro-intestinal endoscopy is a discomforting procedure and adds to the financial burden therefore majority of patients are reluctant to go for it. However it is proven that routine use of upper gastrointestinal endoscopy can delay laproscopic cholecystectomy with clinical benefits. Thybusch et al reported in his study that management plan was changed in 8.3% of patients who went for endoscopy before laproscopic cholecystectomy [9]. In another study management plan changed in 3.1% of patients [2]. Sasoda et al reported that among 2800 patients who went for endoscopy, surgery was delayed in patients with active ulcer and symptoms totally resolved in 16 patients after medical treatment and cholecystectomy was not done [10].
Abnormal findings on upper gastro-intestinal endoscopy were found in 66.42% of patients in our study while Ibrahim et al reports abnormalities in 47.3% of his patients of his study. He reported gastritis as the most common abnormality found on endoscopy which corresponds with the results for our study [7]. 23.03% of patients from our study had gastritis. Second most common finding in our study was gastric ulcer followed by duodenal ulcer. Other abnormalities of our study include duodenal ulcers (10.2%), GERD (6.8%), esophagitis (5.75%), polyps (

CONCLUSION
If endoscopy is added to routine investigations for symptomatic gall stones, this could lead to more clear cause for pain and significantly reduces the chances for postcholecystectomy syndrome. Gastritis and peptic ulcer disease were mostly commonly found on endoscopy and can be easily treated by proton pump inhibitors and H.Pylori eradication therapy bringing improvement in symptoms whereas laproscopic cholecystectomy can be taken place later in time.

CONSENT AND ETHICAL APPROVAL
As per international standard or university standard guideline patients consent and ethical approval has been collected and preserved by the authors.