CHOLECYSTOSONOGRAPHIC EVALUATION OF THE PREVALENCE OF GALLBLADDER DISEASES A UNIVERSITY HOSPITAL EXPERIENCE

MANOJ PANDEY, MS, AJAY K. KHATRI, MS,

BIMAL P. SOOD, MD, RAM C. SHUKLA, MD,

AND VIJAY K. SHUKLA, MCH(CARDIFF)

Ninety-five healthy volunteers and 515 patients with problems other than those of the biliary tract were examined using real-lime, gray-scale, B-mode ultra-

sonography. Eighty-two patients (13.44%) were found to have asymptomatic gallbladder disease: 68 (11.14%) had cholelithiasis, 5 (0.81%) had acalculus cholecystitis. and 2 (0.32%) had polyps. Three cases of carcinoma of the gallbladder were also detected, suggesting that ultrasound examination of the high- risk population in an endemic area should not be confined to the disease concerned but that the gall- bladder of such patients should also be screened to pick up asymptomatic gallbladder disease. Hence ul- trasound can be used as a screening modality for the early detection of carcinoma of the gallbladder. 0 Elsevier Science Inc., 1996

KEY \VOKI)S:

Ultrasonography: Cholelithiasis; Carcinoma of the gallbladder; Polyp; Screening.

INTRODUCTION

The history of gallstone disease dates as far back as human civilization. Sir Gordon Taylor (1937) recalled a mummy of a priestess of Aman of the XXIst dynasty (1500 I,~) that was presented to the Royal College of

Surgeons by Sir Graftan Elliot Smith in 1909 (1). The gallbladder of this mummy was full of small spheri- cal stones. However, credit for the first description of

gallstones in humans goes to Binivinieni, in the 15th

century (2). Carcinoma of the gallbladder was first described by DeStoll in 1777 (3). Graham and Cole

(1920) developed oral cholecystography for preoper-

ative visualization of the gallbladder (4, 5). Mirizzi

and Losada (1931) first recognized the value of oper- ative cholangiography (6). Hublitz et al. (7) in 1972

first suggested the use of ultrasonography for the nonvisualized gallbladder. Since then, because of its

noninvasiveness, speed of examination, and proven

accuracy, sonography has become the first line of in- vestigation for the hepatobiliary system. In spite of

many advances in diagnostic imaging, biliary malig-

nancies continue to elude radiologists. As surgical

techniques improve, it has become more important to diagnose biliary malignancies early to achieve

maximum benefit.

Gallbladder diseases are very common in eastern

Uttar Pradesh and western Bihar regions of India. as

is carcinoma of the gallbladder (8). We carried out this study to evaluate the prevalence of gallbladder

disease in asymptomatic patients and healthy volun-

teers.

E‘rom tile University Departments of Surgery (M.P., A.K.K.. V.K.S.) and Radiodiagnosis (B.P.S.. R.C.S.). Institute of Medical Sciences. Banaras Hindu University, Varanasi, India.

Address reprint requests to: Vijay K. Shukla. MCh. Department of Surgery, Institute of Medical Sciences, Banaras Hindu Univer- sity, Varanasi 221 005, India.

Received July 20, 1994; revised December IO. 1994: accepted December 20. 1994.

MATERIALS AND METHODS

Ultrasonographic screening was carried out in 95 healthy volunteers and 515 patients (males and fe- males) who presented with problems other than those of the biliary system, in the surgical and radio- logical unit of University Hospital, Varanasi, India.

CLINICAL IMAGING 1996;20:269-272 0 Elsevier Science Inc., 1996 655 Avenur of the Americas. New York, NY 10010

OHS!)-7071/96/$15.00 SSDI o89n-;o71(~)5)00034-N

270 PANDEY ET AL. CLINICAL IMAGING VOL. 20, NO. 4

After an overnight fast, real-time, gray-scale, B-mode ultrasound scanning (Sonoline 250, Siemens) was done with the subject in the supine and the right lat- eral position, using a sector mechanical trans- ducer (3.5 and 5 MHz). Films were recorded using an automatic multiformat camera (Adonis).

RESULTS

The incidence of gallbladder disease in the group studied was 13.44%. Cholelithiasis was present in 68 (11.14%); acalculus cholecystitis, in 5 (0.81%); carcinoma of the gallbladder, in 3 (0.48%); and gall- bladder polyps, in 2 (0.32%). Sludge only was pres- ent in 4 (0.64%) subjects (Table 1).

For the 610 subjects screened (age range of 20 to 70 years), a male-female ratio 1:1.5 was observed (Table 2). The male-female ratio in asymptomatic patients with gallbladder disease (n = 82) was 1:2.28, with a peak incidence in the fifth decade (Ta- ble 3).

Of the 515 asymptomatic patients screened, the majority were pregnant women (28.34%). Benign prostatic hyperplasia was present in 133 (25.82%) and Koch’s abdomen, in 92 (17.86%) (Table 4).

Sonographic findings in 82 patients with asymp- tomatic gallbladder disease were as follows: echo in 61 (74.39%) acoustic shadowing in 65 (79.26%), thick wall in 47 (57.30%), gallbladder wall edema in 3 (3.67%), polyp in 1 (1.2%), gallbladder mass in 3 (3.6%), and liver metastasis in 2 (2.4%) patients (Ta- ble 5).

Sonographic abnormalities were detected in 28.00% of pregnant women, 17.8% of healthy volunteers, 14.63% of patients with benign prostatic hyperpla- sia, and 12.19% of patients with Koch’s abdomen, among others (Table 6).

In comparison to the incidence of asymptomatic gallbladder disease in normal subjects (17.8%), sub- jects with disease other than that of heptobiliary sys- tem showed a lower incidence, 12.6%.

DISCUSSION

Since the first report of Leopold and Sokoloff (9) ul- trasonography has established itself as a first line of investigation in gallbladder diseases. The reported accuracy of ultrasound in various series is 90 to 98% (10-15).

Benign prostatic hyperplasia Pregnancy Carcinoma, cervix Carcinoma, stomach Renal calculus with hydronephrosis Koch’s abdomen Carcinoma, breast Appendicitis Thyroid, carcinoma Retroperitoneal mass

Total

133 146

49 12 21 92 32

7 12 11 -

515

25.82 28.34

9.51 2.33 4.07

17.86 6.21 1.35 2.33 2.13

100.00

Pant and Gupta (16) in 1986 examined 2500 patients with ultrasound and found stones in 62 (2.48%), while

subjects, an incidence of 11%. In the present study

Brinholz (1982) (17) studied as asymptomatic popula- 68 patients had asymptomatic gallstones. This varia-

tion of 581 subjects and found silent gallstones in 64 tion of incidence in various series may be due to di- verse dietary habits, and cultures may be responsible

TABLE 1. Ultrasonographic Diagnosis in Asymptomatic Patients with Gallbladder Disease

n %

Cholelithiasis 68 11.14 Carcinoma of the gallbladder 3 0.48 Acute cholecystitis 5 0.81 Gallbladder polyps 2 0.32 Sludge only 4 0.64 Total 82 100.0

TABLE 2. Age and Sex Distribution of All Subjects Screened

Age range Ivrl

Male Female

n % n %

21-30 3 0.49 81 13.27

31-40 9 1.40 68 11.14 51-50 54 8.85 159 26.06 51-60 74 12.13 48 7.86 61-70 101 16.55 13 2.13

Total 241 39.5 369 60.49

TABLE 3. Age and Sex Distribution of Patients with Asymptomatic Gallbladder Disease

Male Female

n % n %

21-30 0 0.00 15 18.29 31-40 1 1.20 10 12.19 41-50 9 10.90 20 24.39 51-60 8 9.75 8 9.75 61-70 7 8.40 4 4.87

Total 25 30.48 57 69.50

TABLE 4. Diagnoses in Screened Population Before Ultrasonography

n %

OCTOBER-DECEMBER 1996 PREVALENCE OF GALLBLADDER DISEASES 271

TABLE 5. Sonographic Morphology in Patients with Asymptomatic Gallbladder Disease

n % ___~__ __- Echo 61 74.39

Acoustic shadowing 65 79.26

Contour irregularity 10 12.00

Thick wall 47 57.30

Shadow changes with posture 37 45.20

Calcification 6 7.3

Sludge 22 26.82

Polyp 1 1.20

Intraluminal 3 3.60

Liver infiltration 1 1.20

Liver metastasis 1 1.20

Gallbladder wall edema 3 3.67

Ascites 1 1.20

with gallbladder wall thickening. Of the patients screened in the present study, 1.2% were found to have gallbladder polyps, an incidence similar to that of earlier reports (21).

Carcinoma of the gallbladder is associated with stones in 40 to 100% of patients. The importance of the development of carcinoma in patients with asymptomatic gallstones has been well emphasized. In the present series. carcinoma was present, in ad- vanced stage, in 0.48% of patients and in 2 it was as- sociated with gallstones. The survival of patients with carcinoma of the gallbladder varies with the stage of the disease at the time of presentation. Pa- tients with stage I disease have a 90 to 95% survival rate while the rates are 65 to 90% for stage II and 8 to 20% for stage III. Most of the patients with stage IV disease die within 6 months (22-25).

for the wide geographical variation in the distribu- tion of gallstone disease.

Bertoli et al. (18) reported increased stone forma- tion during pregnancy and suggested a temporary al- teration in the pathophysiology of gallbladder hmc- tion, which becomes normal after termination of pregnancy. In the present series the highest inci- dence of stones was found to be associated with preg- nancy (28%). This may be due to the fact that preg- nant females formed the largest group screened (28.34%). One other large group of patients (those with benign prostatic hyperplasia) had an incidence of 25.8%.

The incidence of benign neoplasm of the gallblad- der is reported to be 0.3 to 20.0%, most of it adeno- myomatosis.

Gallbladder polyps have been found in 1% of pa- tients undergoing cholecystectomy (19-21). The evi- dence for the adenoma-adenocarcinoma sequence is abundant (20). The risk of developing carcinoma in a polyp is reported to be about 0.0020 to 0.0160% per year. The risk increases with the size of the polyp or

The peak incidence of asymptomatic biliary dis- ease in the present series occurred in women in the fifth decade; this is also the peak age for carcinoma (8) in this region. Two-thirds of carcinomas are asso- ciated with stones. We suggest that every woman over the age of 40 years living in an endemic zone should be screened sonographically at least annu- ally. The cost of such ultrasound screening in Vara- nasi, India, is $5.00 and the additional gallbladder portion of the examination does not cost extra. We further suggest that every female who is referred to a radiologist for ultrasonography should be screened for gallbladder disease as well: thus we might be able to pick up cases of carcinoma earlier and may effect a worthwhile cure.

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TABLE 6. Diagnoses in Asymptomatic Gallbladder Disease Patients Before Ultrasonography

4.

5.

Koch’s abdomen

Pregnancy

Benign prostatic hyperplasia

Carcinoma, stomach Renal calculus with hydronephrosis

Carcinoma. cervix

Carcinoma, breast

Recurrent appendicitis

Retroperitcmeal mass

Healthy volunteer

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n %

10 12.19

23 28.00

12 14.63

4 4.87

2 2.44

5 6.09

4 4.87

2 2.44

3 3.65

17 20.73 _..__ _

82 100.00

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