“Gastroesophageal Mucosal Injury after Cholecystectomy: An Indication for Surveillance?” is a new study published by T. Walsh et al in the current issue of JACS (Journal of the American College of Surgeons). The authors evaluate the incidence of stomach bile pooling detected by endoscopy in patients before and after cholecystectomy. They further measure the bile reflux index, cellular proliferation marker Ki67 and tumor-suppressor gene p53 in biopsies taken from the gastro-esophageal junction and gastric antrum. The analysis show that cholecystectomy increases the incidence of bile reflux and bile induced damage of gastric and esophageal mucosa. Chronic bile induced esophagitis and gastritis increase the incidence of gastric and esophageal cancer. The role of bile reflux in the pathogenesis of Barrett’s esophagus is well established and 10% of patients with Barrett’s esophagus develop esophageal adenocarcinoma.
At Houston heartburn and Reflux Center, more than 50% of patients presenting for GERD evaluation have already underwent a cholecystectomy. Chronic proton pump inhibitor use by GERD patients may increase the incidence of biliary stasis and choleltihiasis. However, many patients have had their GERD symptoms mistaken for biliary colic. Cholecystectomy is a very common procedure performed by general surgeons. Primary care physicians tend to order a gallbladder ultrasound/HIDA scan for epigastric pain much more commonly than upper endoscopy and ambulatory pH testing. Cholelithiasis is present in 30% of the population. Most cholelithiasis cases need no intervention. It is crucial to differentiate GERD pain from biliary colic prior to committing a patient to any surgical intervention. A healthy gallbladder has several important functions some of which we still don’t know about. This study shows that cholecystectomy increases the risk of bile reflux and esophago-gastric mucosa injury. I suspect the risk of bile reflux and mucosal injury is highest in GERD patients who undergo an unindicated cholecystectomy. Biliary colic and GERD pain may have overlapping presentations. A thorough history taking and sharp clinical acumen coupled with proper testing and evaluation are therefore needed to avoid doing harm and unnecessary surgery.
Reference
Cahan MA: Proton pump inhibitors reduce gallbladder function. Surg. Endosc. 20 (9): 1364–1367.