Correlation between gallbladder size and acute cholecystitis in cholecystectomy specimen, cross sectional study

Authors

Abstract

Aim The symptoms of acute cholecystitis can sometimes be misleading, making ultrasound confirmation the most reliable method. More sensitive imaging criteria will be very helpful in managing surgical patients with acute cholecystitis, especially those who also have other health problems.
Materials and Methods Pathological reports from 1084 patients in the Riyadh area of Saudi Arabia who had laparoscopic cholecystectomy were looked at in a cross-sectional study from January 2009 to December 2018. We measured the length, width, and gallbladder space and correlated the pathological findings with acute cholecystitis.
Results A bivariate correlation analysis using Spearman’s rho (as cholecystitis status is not normally distributed) was performed to find out the relationship between gallbladder size and cholecystitis. Hence, when the length of the gallbladder increases by more than 5 cm, the cholecystitis status seems to move towards acute cholecystitis.
Discussion We can link the diagnosis of acute cholecystitis to a gallbladder length of more than 5 cm. This implies that it could serve as a simple and effective radiological test to identify acute cholecystitis in challenging cases.

Keywords

Introduction

Acute cholecystitis is acute gallbladder inflammation that is caused in approximately 90% of cases by cholelithiasis. Gallstone-related disorders are one of the costliest in the domain of gastroenterology and thus have a substantial effect. The Gallstone formation is complex. Gallstone disease becomes more common as people get older. Gallstones form as a result of a carbohydrate- and fat-rich diet, as well as a lack of exercise in the Western hemisphere. Genetic differences in cholesterol carriers are another important risk factor. The medical history, physical examination, abdominal ultrasound, and infection parameters in analytical laboratories are used to make a diagnosis [1].
Acute cholecystitis is a continuous infection of the gallbladder caused by gallstones obstructing the cystic duct. Congestion and edema are apparent symptoms during the first 2-4 days, which is referred to as the “edematous cholecystitis phase.” Necrosis of the gallbladder, marked by bleeding and necrosis, develops in the first week. After the first week, the illness progresses to the purulent phase, also known as suppurative cholecystitis. If the illness is not managed at this stage, it progresses to subacute cholecystitis and, subsequently, to chronic cholecystitis. Gallbladder rupture during the hemorrhagic and necrotic stages, peri-gallbladder infection, and internal biliary fistula during the purulent phase are complications of cholecystitis [2]. Gallstone disease is a prominent source of illness in the United States, and diagnosis and/or treatment usually necessitate surgical or endoscopic intervention. Although gallstone illness is most commonly associated with the inflammatory result of the disease of cholecystitis, gallstones can also cause other symptoms such as gallstone ileus, Mirizzi syndrome, and Bouveret syndrome [3, 4] The reported fatality rate of acute cholecystitis is around 3%, but it rises with age or illness of the patient [5].

Materials and Methods

From January 2009 to December 2018, all pathological reports of 1084 patients with cholecystectomy specimens after laparoscopic cholecystectomy in Sulayel General Hospital, Riyadh area, Saudi Arabia, were examined in a cross-sectional study. Appropriate demographic data, such as age, gender, surgery date, and size of the gallbladder size (length and width) from the gross description of the gallbladder pathology report were collected. Pregnancy and any patients with vital missing information in their records were excluded from this investigation.
Body weight, body mass index, and past medical history were missing from pathology reports.
The following inquiries were made: Is there a difference between male and female cholecystitis patients? The Mann-Whitney U test was employed to determine statistical significance. Is there a link between age and the presence of cholecystitis? For evaluation, bivariate correlation analysis with Spearman’s rho was performed. Is there a link between gallbladder size and cholecystitis status? To assess statistical significance, perform a bivariate correlation analysis with Spearman’s rho. SPSS software (version 12) was used to analyze all of the data. A probability value of less than 0.05 was regarded as significant.
Ethical Approval
This study was approved by the Ethics Committee of Imam Muhammad ibn Saud Islamic University (Date: 2024-06-20, No:663/2024).

Results

The descriptive analysis with graphical illustrations presents the demographic profile and background of the patients. This is followed by the Mann-Whitney U test in order to identify the difference in cholecystitis found in male and female patients. Bivariate correlation analysis using Spearman’s rho was used to evaluate the correlations between the size of the gallbladder and the chance for cholecystitis.
Demographic Profile and Background of the Patients: There were 1084 patients in the study. Demographics are vital to the understanding of the background of the respondents. That provides some insights into the differences in results in the study. The age of the patients ranges from 13 years to 88 years with a mean of 36.87 ± 12.46 years. It is shown that most of the patients are less than 50 years old. The majority of 79.6% of the patients are female and 20.3% are male Only 2 have not marked their gender, the majority of 79.6% of the patients are female and 20.3% are male. The majority 97.5% of the patients are Saudi Arabian and 2.5% are non-Saudi. The nationality of 3 patients has not been recorded.
The majority of 81.2% of the patients have Chronic cholecystitis and only 8.8% have Acute cholecystitis. However, 10% of the patients have Acute or chronic cholecystitis (Fig. 2). The following scatter plot shows the variation of cholecystitis against the length of the gallbladder, scatter plot of gallbladder length vs cholecystitis status (1: acute, 2: acute on chronic, 3: chronic). It is clear that acute cholecystitis appears above the 5 cm length of the gallbladder (Fig. 3).
To evaluate the difference in cholecystitis between male and female patients, a normality test was performed on their cholecystitis status. Since the test p-value (0.001) is less than 0.05, the cholecystitis status is not normally distributed. Therefore, a Mann-Whitney U test was used to determine the differences in cholecystitis between males and females (Tables 1, 2, and 3). The results show that females have significantly higher chronic cholecystitis compared to males, with a p-value of 0.001 (< 0.05).
To evaluate the correlation between age and cholecystitis status, a bivariate correlation analysis using Spearman’s rho (as the cholecystitis status is not normally distributed) was performed to find out the relationship between age and cholecystitis. As the Spearman correlation is -0.049, there is a weak negative correlation between age and cholecystitis. Further, the relationship is not significant (p = 0.106 > 0.05) (Table 4).
To assess the correlation between the size of gallbladder and cholecystitis status, three available data on gallbladder size were used for the correlation analysis. The following table shows the descriptive statistics of the three measures. The length of the gallbladder (N = 1059) ranges from 2.00 cm to 25.00 cm with a mean of 7.89 ± 1.72 cm. The width of the gallbladder (N = 686) ranges from 0.20 cm to 11.00 cm with a mean of 2.59 ± 0.84 cm. The area of the gallbladder (N = 686) ranges from 1 cm2 to 84 cm2 with a mean of 21.11 ± 9.96 cm2. Bivariate correlation analysis using Spearman’s rho (as cholecystitis status is not normally distributed) was performed to find out the relationship between the size of the gallbladder and cholecystitis. The results are shown in (Tables 5, 6) below. All the three Spearman correlations are negative, weak, and significant (p < 0.05). Hence, when the size of the gallbladder increases, the cholecystitis status seems to move towards acute cholecystitis.

Discussion

Age-related presentations of cholecystitis were changes in the elderly and geriatric groups differed, and in some situations, they were diametrically opposed. The dynamics of the factors in relation to surgery were not well represented in the elderly, especially in the advanced group [6]. When compared to young individuals with acute cholecystitis, older individuals had a greater level of leukocytes. General surgeons must be careful when they are looking at older patients with pain in the right upper quadrant of their abdomen [7]. Our data could not make a correlation between age and cholecystitis.
The female gender was found to be positively and independently linked with cholelithiasis [8]. Females were found to have an 86% risk of developing chronic cholecystitis. Stomach and intestinal metaplasia were more positively affected by neutral mucin than by sulfated mucin [9]. Females were more likely to have choledocholithiasis if they had a high body mass index, high bilirubin, high alkaline phosphatase, and high serum glutamic-oxaloacetic transaminase levels [10].
If the gallbladder obstruction continues, the concentrated bile might cause chemical cholecystitis. When paired with infection in acute bacterial cholecystitis, the accompanying enlargement and pain might last or worsen over time, resulting in hyperthermia and the development of a perceptible abdominal mass [11]. Gallbladder distension causes pain in ten of the twelve patients. 70% of the time, the pain is located in the right upper quadrant or in the epigastrium. The pressure- volume relationship in the gallbladder could not be described mathematically. The cystic duct release pressure ranged from 3 to 44 mmHg [12]. When the intraluminal tension is elevated experimentally, gallbladder fluid secretion decreases, revealing systems that resist secretion in this condition. Senior surgeons think that high intraluminal pressure plays a role in the development of acute cholecystitis [13].
Experiment results show that intramural neurons impact prostaglandin-induced gallbladder fluid production in experimental cholecystitis. Gallbladder inflammation may be connected with prostaglandin-induced stimulation of intrinsic neurons, which may drive epithelial cells to secrete fluid. This secretion produces gallbladder distension by raising intraluminal pressure in the blocked gallbladder. This mechanism may play an important role in the pathogenesis of acute cholecystitis, and this could explain our finding of a strong association between the larger size of the gallbladder and acute cholecystitis finding in pathology report [14]. A gallbladder width of 3.12 cm can be used to identify acute cholecystitis based on computed tomography (CT) findings (gallbladder breadth, length, stone, wall thickening, and pericholecystic fluid). As a result, a gallbladder width of 3.12 cm measured with CT can be a simple and reliable way to tell if someone has acute cholecystitis, which is caused by a restriction in bile flow [15]. Our study showed gallbladder length of more than 5 cm in length is highly suggestive of acute cholecystitis.

Limitations

Lack of data regarding pregnancy status is presumed to affect the statistical results, although it should not affect the overall statistical sensitivity, as surgery for pregnant women with acute cholecystitis is generally managed conservatively, and patients are typically operated on after delivery.

Conclusion

Increased gallbladder size was found to be linked to the diagnosis of acute cholecystitis, which can be simply detected by ultrasound. It could be used as a simple and effective biomarker to show other criteria to diagnose acute cholecystitis through non-invasive methods.

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