Routine upper gastro-intestinal tract endoscopy before elective cholecystectomy for symptomatic gallstones-justified

Gallstones are common in Western countries and increasing in developing countries through adoption of western lifestyle. Gallstones may cause life-threatening complications, including acute cholecystitis, acute cholangitis, and acute pancreatitis. Cholecystectomy is the treatment of choice for symptomatic gallstones. Presentation of symptomatic gallstones may be indistinguishable from that of other upper gastro-intestinal tract (UGI) pathologies. Some surgeons routinely perform preoperative UGI endoscopy to diagnose and treat concomitant UGI pathology. A prospective cross-sectional observational study was undertaken at University of Pretoria teaching hospitals to evaluate this practice. Patients aged 18 years and older, with symptomatic gallstones but did not satisfy Tokyo guidelines for acute cholecystitis were recruited. UGI endoscopy was performed before cholecystectomy. There were 124 patients, 110 (88.7%) females and 14 (11.3%) males, mean age 44.0 (13.2) (range: 22–78) years. Most common symptoms were right upper quadrant (RUQ) pain (87%), epigastric pain (59.7%), nausea (58.1%) and vomiting (47.9%). Clinically, 80% had RUQ tenderness and 52.4% epigastric tenderness. UGI endoscopy found 35.4% pathology, 28.2% were active, and comprised acute gastritis (27.4%), peptic ulcers (4.8%), duodenitis (3.2%) and oesophagitis (2.4%). Twelve patients had more than one pathology. This warranted treatment before elective cholecystectomy and justifies the practice of routine preoperative UGI endoscopy.

December 2016 to July 2019.Thus, patients with asymptomatic gallbladder stones and definite acute cholecystitis were excluded.
All patients had thorough history taken, a full physical examination, and relevant blood tests done, which included white cell count (WCC), C-reactive protein (CRP), liver function tests and serum lipase.Abdominal ultrasonography for gallstones was performed as part of the diagnostic work up.Patients were subjected to UGI endoscopy before elective cholecystectomy and those with UGI pathology were appropriately treated pre-operatively.

Statistics consideration
A biostatistician determined that a minimum of 62 patients would be required to reliably predict that 20% of patients would have a concurrent UGI pathology at 95% confidence interval.Nominal statistics were expressed as percentages and proportions.

Ethical considerations
The study was approved by the Research Ethics Committee of the University of Pretoria, Faculty of Health Sciences (reference 386/2016) and conducted according to the Helsinki Declaration on research on human subjects.Informed consent to participate in the study was obtained from all patients.

Results
One hundred and twenty four patients were enrolled in the study.Patient demographic details are shown in Table 1.It is noted that the mean age was 44.0 years, a majority were female (88.7%) and black Africans (55.6%).The predominant symptoms were right upper quadrant (RUQ) (87%) or epigastric (59.7%) pain and major physical signs were RUQ (80.6%) or epigastric (52.4%) tenderness.
UGI endoscopy detected active UGI pathology in 28.2% where acute gastritis was most common (27.4%) and peptic ulcer the most serious (4.8%).There were 12 patients with hiatus hernia but only three of them had active pathology.Therefore 44 (35.4%) had abnormal UGI endoscopy findings.

Discussion
Gallstone disease is a leading cause of elective abdominal surgery 5 .However, a majority of gallstones are quiescent, being discovered incidentally during radiological examinations, particularly ultrasonography, undertaken for other reasons, or during abdominal surgery, or at autopsy 4,5 .Symptomatic gallstones may lead to complications some of which may be life-threatening such as acute cholecystitis, acute cholangitis, acute pancreatitis and cholangiocarcinoma 4,5 .A majority of gallstones are cholesterol stones associated with a western lifestyle and diet.The South African black population is rapidly westernising and as such they show increasing incidence of gallstones 2,3 .Presentation of symptomatic gallstones may be indistinguishable from that of other causes of foregut or UGI pathology [6][7][8] .Consequently, a number of patients may undergo cholecystectomy, the management of choice for symptomatic gallstone disease 4,5 , while the actual cause of their symptoms is a different UGI pathology 10,11,13,14 .Such patients may continue to experience UGI symptoms after successful and uneventful cholecystectomy as postcholecystectomy syndrome [15][16][17][18] .Although there are other possible causes of postcholecystectomy syndrome [19][20][21][22][23] , most concurrent UGI pathology can be readily diagnosed by UGI endoscopy and appropriately treated before elective cholecystectomy 24 .Indeed, cholecystectomy may be cancelled in such cases [10][11][12]15 .

Conclusion
The practice of routine UGI endoscopy before elective cholecystectomy has been justified by the finding of active UGI pathology which warranted treatment in a significant proportion of patients with presumed symptomatic gallstones in an African setting.

Table 1 .
Clinical and upper gastro-intestinal tract endoscopy findings in patients with presumed symptomatic gallstones.# RUQ = right upper quadrant.*12 patients had more than one pathological endoscopy finding.This prospective study found concurrent UGI pathology in 35.4% patients and 28.2% had active pathology.This concurs with most published prevalence reports of 20-46% concurrent UGI pathology.The current study validates our practice of UGI endoscopy and treatment of associated UGI pathology before elective cholecystectomy in a South African hospital patient population which is predominantly black.Indeed, it is the first report of its kind in South Africa or sub-Saharan Africa.It is probable that prior diagnosis and treatment of co-existing UGI pathology would reduce the incidence of postcholecystectomy syndrome.However, this would need to be confirmed by a prospective randomized trial where some patients would undergo UGI endoscopy and treatment of UGI associated pathology before elective cholecystectomy for cholecystolithiasis, while others would not.