2020, Number 1
Factors associated with severity of grade I cholecystitis vs grade II in adult female patients
Full text
10.35366/92705
Language: English/Spanish [Versi?n en espa?ol]
References: 15
Page: 6-12
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ABSTRACT
Introduction: Cholelithiasis is a great public health problem in Mexico. Obesity plays a role during genesis of gallbladder disease, however, is not clear if it affects the severity of cholecystitis. Objective: The aim of this study was to evaluate risk factors for severity in cholecystitis (grade I vs grade II) in female patients. Material and methods: Cross-sectional study to evaluate risk factors to severity during cholecystitis (grade I vs grade II) in women that were underwent to laparoscopic cholecystectomy. We evaluated and compared: age, weight, height, body mass index (BMI), waist, hip, waist-hip index (WHI), blood pressure, glucose, cholesterol, high density lipoproteins (HDL), triglycerides, leucocytes, neutrophils, surgical time, presence of type 2 diabetes, arterial hypertension, hypertriglyceridemia, hypercholesterolemia, dyslipidemia, central obesity, obesity by WHI, and metabolic syndrome. Results: We analyzed 132 patients that were underwent to laparoscopic cholecystectomy. Only triglycerides (155.9 vs 178.4; p = 0.008) and presence of hypertrygliceridemia (40.5% vs 70.8%; p = 0.001) were statistical different. Conclusions: Neither obesity by BMI nor central obesity (by waist or WHI) have a relation with severity of cholecystitis, but levels of triglycerides and presence of hypertriglyceridemia could be risk factor for severity (grade II).INTRODUCTION
Nowadays, cholelithiasis is a public health problem.1 Necropsy studies reveal that 12% of men and 24% of women suffer from this entity.2 Although 80% of patients with cholelithiasis may remain asymptomatic, the rest present with symptoms such as biliary colic, and complications such as cholecystitis, choledocholithiasis, pancreatitis, and cholangitis, among others.2
The risk factors for cholelithiasis and cholecystitis are well defined. While obesity is classically considered as an etiologic factor, central obesity, and waist-to-hip ratio (WHR) are suggested to play an important role in the severity of cholecystitis.3
The aim of this study is to evaluate which factors may condition the occurrence of grade II cholecystitis in a female population undergoing laparoscopic cholecystectomy.
MATERIAL AND METHODS
From January through December 2018 a cross-sectional study was performed at the General Hospital de Zona No. 35 of the Mexican Social Security Institute (HGZ No. 35, IMSS) in Ciudad Juarez, Mexico. Female patients aged 18 to 65 years, admitted to hospital with a diagnosis of acute cholecystitis and who underwent laparoscopic cholecystectomy were included.
Patients with liver diseases such as cirrhosis, cysts or liver tumors of any etiology, cancer of the rest of the digestive tract, pregnancy, and patients whose cholecystectomy had been converted from laparoscopic to open cholecystectomy were excluded.
The patients were divided into two groups: group 1 included patients with acute cholecystitis without any other complication or grade I cholecystitis, and group 2 included patients with complicated acute cholecystitis (choledocholithiasis, cholangitis, biliary pancreatitis, mucocele, empyema, etc.) without any organic dysfunction or grade II. The diagnosis of acute cholecystitis, as well as the differentiation between grade I and grade II acute cholecystitis, was determined based on the operative findings and the criteria of the Tokyo 18 guidelines (Tables 1 and 2).4
Laparoscopic cholecystectomy was performed as a treatment for acute cholecystitis. The operation was performed by the same surgical team using the standard four-port technique.5 The procedure was performed during the same hospitalization period.
Following parameters were measured: age, weight, height, body mass index (BMI), waist, hip, waist-to-hip ratio (WHR), blood pressure, glucose, cholesterol, high-density lipoprotein-cholesterol (HDL-C), triglycerides, white blood cells, neutrophils, surgical time, and presence of type-2 diabetes (DM2), high blood pressure (HBP), hypertriglyceridemia (≥ 150 mg/dl), hypercholesterolemia (≥ 200 mg/dl), dyslipidemia (altered cholesterol and/or triglycerides), abdominal obesity (hip 88 cm), waist-to-hip ratio (WHR) obesity (≥ 0. 85), and metabolic syndrome (MS).
Weight and height were measured with the patient barefoot and wearing a hospital gown, BMI was calculated by dividing weight (kg) by height squared (meters). Waist and hip circumference were measured with a flexible tape measure with the patient in fasting state, always in the standing position, and the tape placed at the level of the navel for the waist and at the level of the most prominent gluteal part for the hip.
Since no experimental intervention was performed, this study did not require approval by the institutional bioethics committee if the patients' informed consent for the surgical procedure was already obtained.
Statistical analyses of the parameters were performed with the SPSS program (version 23.0; Chicago, Il). Qualitative variables were compared with the χ2 test, and quantitative variables with Student's t test (normal behavior variables) and the Mann-Whitney U test (abnormal behavior variables). A p value < 0.05 was considered statistically significant.
RESULTS
We evaluated 132 patients who met the inclusion criteria, with a mean age of 38.6 years, a mean BMI 31.8 kg/m2, and a mean triglyceride level of 164 mg/dl; the rest of the parameter values are shown in Table 3.
Regarding the comorbidities presented in the total number of patients, we found a prevalence of DM2 of 39.4%, HBP of 9.1%, hypertriglyceridemia of 51.5%, among others. The remaining percentages are described in Table 4.
Quantitative variables were compared by groups (grade I vs. grade II) and statistically significant differences were observed in the mean triglyceride levels, and in white blood cell and neutrophil counts. The rest of the values that were not statistically significant are shown in Table 5.
Regarding comorbidities between the groups, a statistically significant difference was seen in the presence of hypertriglyceridemia and dyslipidemia. The rest of the comorbidities that were not statistically significant are detailed in Table 6.
DISCUSSION
Acute cholecystitis is the most common complication of cholelithiasis, with a mortality of approximately 3%. The standard treatment is laparoscopic cholecystectomy;6 however, open cholecystectomy continues to be performed in some second level care centers.7
Overweight and obesity increase the risk of cholelithiasis8 through the increased secretion of cholesterol in the liver, which produces supersaturation and precipitation of bile with the consequent formation of calculi. The role of obesity in the development of gallstones is clear, but its role is debatable with respect to its severity. The presence of obesity in the context of cholelithiasis implies a chronic visceral inflammatory state that could influence the severity of acute cholecystitis. However, in this study the means between groups (grade I vs. grade II) were not statistically significant in relation to BMI, waist, hip, and WHR. This could suggest that, although obesity predisposes to a visceral inflammatory state at the onset of the disease, once cholecystitis is established, obesity per se does not seem to influence the severity of the condition.
Although the relationship between serum total cholesterol levels and the frequency of cholelithiasis has not been demonstrated, we were able to observe that both the mean triglyceride levels (155.9 vs. 178.4 mg/dl; p = 0.008) and the presence of hypertriglyceridemia (40.5% vs. 70.8% mg/dl; p = 0.001) were correlated with group 2 (grade II cholecystitis). Alterations in lipid metabolism are a pivotal element in the development of cholelithiasis in patients with obesity. This duality is characterized by hypertriglyceridemia that correlates with lack of gallbladder motility9 being therefore a factor in the development of cholelithiasis. The results of this study suggest that elevated triglyceride levels do significantly increase the risk of severity (at least to grade II), which would condition both an aggravation of the disease and act as a risk factor for severity.
Other studies have suggested that obesity may be a protective factor against the severity of cholelithiasis in male patients, and that visceral fat may have a protective function against the inflammatory state in cholecystitis.8 These same results have not been reproduced in other studies.10,11 Cholelithiasis has a direct relationship with non-alcoholic grade liver,12 and fatty infiltration in visceral organs such as the liver can cause chronic inflammation, so the assumption that visceral fat conditions protection could be contradictory.13
DM2 and HBP are considered risk factors for developing acute cholecystitis.14 Fagan et al. demonstrated that DM2 did influence the development of gangrenous cholecystitis.15 However, our results suggest that both DM2 and HBP appear not to influence the development of complications. This has been a subject to discussion and larger studies are required to corroborate the true role of these comorbidities in the severity of cholecystitis.
CONCLUSION
In the present study, the results suggest that high triglyceride levels could act as a risk factor for grade II cholecystitis. No relationship was demonstrated between obesity measured by BMI, waist, hip and/or WHR with the severity of cholecystitis (grade I vs. grade II). However, more prospective, or multicenter studies are needed to corroborate these findings.
REFERENCES
AFFILIATIONS
1 General surgery and gastrointestinal endoscopy. Hospital General de Zona No. 35, Instituto Mexicano del Seguro Social.
2 Gastroenterology and gastrointestinal endoscopy. Department of Medical Sciences, Universidad Autónoma de Ciudad Juárez. Hospital General de Zona No. 35, Instituto Mexicano del Seguro Social.
Ethical considerations and responsibility: Data privacy. In accordance with the protocols established at the authors\' work site, the authors declare that they have followed the protocols on patient data privacy while preserving their anonymity. The informed consent of the patient referred to in the article is in the possession of the author.
Funding: No external financial support was received for this study.
Disclosure: The authors declare that they do not have any conflict of interest in this study.
CORRESPONDENCE
Juan de Dios Díaz-Rosales. E-mail: jdedios.diaz@uacj.mxReceived: 07/28/2019. Accepted: 11/04/2019