Saudi Journal of Gastroenterology
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Year : 1998  |  Volume : 4  |  Issue : 3  |  Page : 159-162
Symptomatic gallstones: A disease of young Saudi women


Department of Surgery, King Khalid University Hospital, Riyadh, Saudi Arabia

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Date of Submission02-Aug-1997
Date of Acceptance11-Mar-1998
 

   Abstract 

This is a study performed to identify the risk factors for gallstones in Saudis, taking the patient population of King Khalid University Hospital as a sample. Only Saudis with symptomatic gallstones were studied, the parameters being age, sex, weight, body mass index, fertility, age at menarche and age at marriage. The results showed that sex, weight, body mass index and fertility all appeared to be important factors in the development of gallstones and that the condition affects more Saudi females and at a younger age than reported in the literature, probably due to overweight and factors related to reproductivity. We conclude that gallstones are common in Saudi women and affect them at a younger age than western women, weight and fertility appear to be important risk factors.

How to cite this article:
Murshid KR. Symptomatic gallstones: A disease of young Saudi women. Saudi J Gastroenterol 1998;4:159-62

How to cite this URL:
Murshid KR. Symptomatic gallstones: A disease of young Saudi women. Saudi J Gastroenterol [serial online] 1998 [cited 2018 Jul 23];4:159-62. Available from: http://www.saudijgastro.com/text.asp?1998/4/3/159/33911


Gallstones are known to be a disease of fat, forty, fertile females. This needs to be studied in an all Saudi population of symptomatic gallstone patients, in order to see if there are any differences between Saudis and other groups of patients. There is no accurate record of the incidence or prevalence of gallstones in Saudis. Whether it is as high as the 60% reported for Pima Indians over 35 years of age[1] or low, as reported in Japanese women[2] remains to be seen. Other countries with a high reported prevalence include Scandinavian, Northern European countries[3] and Chile[4]. Sub-Saharan Africa has been reported to have a low prevalence[5]. Socio-economic and demographic factors are thought to be the cause of the decreasing prevalence of gallstones in Denmark[6]. Several factors need to be studied in order to see their effects on the Saudi population, many of these factors may overlap. Sex, age, weight, BMI and reproductive factors are studied here to observe their effects.


   Patients and Methods Top


Two-hundred-and-twenty Saudi patients with symptomatic gallstones undergoing laparoscopic cholecystectomy between December 1991 and December 1996 at King Khalid University Hospital in Riyadh were studied with regard to sex, age, weight and height in addition to fertility and ages of menarche and marriage for females. The Body Mass Index (BMI) was used as an estimate of relative weight; BMI = weight in kg/(height in M)2. According to the WHO definition and means of measuring overweight and obesity, a BMI of 25-30 was considered overweight, 30-40 was considered obese and over 40 was considered morbidly obese[7] Calculations of averages, means and standard deviations were done using the biomedical data processing software program (BMDP) of the University of California 7.01 release 1994.


   Results Top


The different age groups and the corresponding percentages and ratios are compared in [Table - 1]. There were 187 females (85%) compared to only 33 (15%) males, in the study with an overall ratio of 5.7:1. This ratio decreases with age. Most of the female patient population was below 40 years of age (59.36%) whereas most of the male population (75.8%) was over 40 years of age.

The age range was 13-90 years with a mean age of 48.4 years (S.D. 15.3). The weight in females ranged between 38-115 kg with a mean of 71.96 kg (S.D. > 15.2). The weight in males ranged between 53-106 kg with a mean of 77.64 kg (S.D. 12.6). The BMI is compared in [Table - 2], 74% of the overall population was overweight (BMI > 25), 57% were obese (BMI > 30) and 6.4% morbidly obese (BMI > 40). The commonest type of stone is the predominantly cholesterol stone found in 84.7% of the patients with the mixed brown stone representing 11 % and the black pigment stone was seen in 4% of the population.

Reproductive data show that the age at menarche ranged between 11 and 16 years with a mean of 12.3 years. Age at marriage ranged between 14 to 26 years with a mean of 18.1 years and the number of children ranged between 0 and 12 with a mean of 5.2 per female patients.


   Discussion Top


Stones are generally reported to be uncommon before the age of 20 years[8],[9], and 40 years is considered as a typical age at clinical diagnosis[10] . This relation to age is supported by the studies that show that the sensitivity of the gallbladder to cholecystokinin (CCK) decreases with aging[11], in addition to the time factor in stone development. In our female patients 59% were younger than 40 and 35% were younger than 30 years of age! Dietary factors and obesity in particular have been linked to gallstone disease as a positive risk factor[12]. In addition, obesity has been linked to cholesterol stones in particular\[13],[14]. About 84.7% of the patients developed cholesterol stones. In a study on Saudis by Al-Nuaim et al[15], the prevalence of overweight and obesity was found to be high compared to western standards and in females the prevalence of obesity was amongst the highest reported. Our results are compared with theirs in [Table - 3]and show considerable increase in all parameters when compared to the already high results shown by them. These results in addition to the fact that 84.7% of our patients had cholesterol stones clearly indicates a close relationship between overweight and cholesterol stone formation.

Increased fertility is another important factor which appears to be especially important in the patients. This factor appears to exert its influence through the hormonal changes occurring during pregnancy and is translated into a female: male ratio of gallstones which is much higher during the reproductive period than after the menopause[16], in addition to the basic hormonal differences between males and females. In our patients this ratio was male: females 1:7.7 in patients below 50 years of age and even as high as 1:13.9 in patients below 40 compared to only 1:3.4 above 50 years.

Average menarche in our group was 12.3 years, average age at marriage was 18.1 years and average parity was 5.2. Ultrasound surveys of pregnant women have found an increase in gallbladder volume and reduced rates of emptying after liquid meals[17],[18]. Others have reported a high prevalence of gallbladder sludge in women who were immediate postpartum although the sludge resolved within a year in most [19] The incidence of sludge appeared to increase steadily during pregnancy and gallstones develop at a lesser rate[20]. Jorgensen found a strong trend toward increasing stone prevalence with increasing childbirths, especially among women aged 30 years [21]. These above observations apply strongly to our patient population with their relatively early menarche, early marriage and high parity.

Other factors have been studied by others but were not included in this study. Chronic use of non­steroidal anti-inflammatory drugs were studied by some and were found not to have a significant impact on the prevalence of gallstones[22]. Hypercalcaemia on the other hand, was studied in the prairie dog and was found to decrease bile flow and increase biliary ionized calcium concentration, effects favoring the precipitation of calcium salts in bile[23]. In addition, certain conditions were found to be associated with a higher prevalence of gallstones such as chronic pancreatitis and duodenal diverticulae[25].


   Conclusion Top


As our study was conducted in a single hospital (King Khalid University Hospital) serving patients mainly from the Riyadh district of Saudi Arabia, our findings cannot be generalized. Nevertheless they represent an interesting observation which requires further in-depth analysis of a much larger population across Saudi Arabia taking into account regional variations. This observation being that gallstones appear to be much more common in Saudi females and appear to occur at a considerably younger age. The principle factors for this early occurrence appear to be overweight, early age of menarche, early marriage and high parity.

 
   References Top

1.Sampliner RE, Bennett PH, Comess LJ, Rose FA, Burch TA. Gallbladder disease in Pima Indians N. Engl J Med 1970;283:1358-64.  Back to cited text no. 1    
2.Nomura H, et al. Prevalence of gallstone disease in a general population of Okinawa, Japan. Am J Epidemiol 1988;128:598-605.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Zahor Z, Stemby NH, Kagan A, Uemura K, Vanecek R, Vichert AM. Frequency of cholelithiasis in Praque and Malmo. An autopsy study. Scand J Gastroenterol 1974;9:3­7.  Back to cited text no. 3    
4.Medina E, Pascual Jp, Medina R; Frequencia de la litiasis biliar en Chile. Rev Med Chile 1983;111:668-75.  Back to cited text no. 4    
5.Adedeji A, Akande B, Olumide F. The changing pattern of cholelithiasis in Lagos. Scand J Gastroenterol 1986;21(Suppl 124):63-6.  Back to cited text no. 5    
6.Jensen KH, Jorgensen T. Incidence of gallstones in a Danish population. Gastroenterology 1991;100:790-4.  Back to cited text no. 6    
7.Joint FAO/WHO/UNU Expert Consultation on Energy and Protein Requirements. WHO Technical Report Series 724 WHO: Geneva 1985;1-67.  Back to cited text no. 7    
8.Andrassy RJ, Treadwell TA, Ratner IA, Buckley CJ. Gallbladder disease in children and adolescents. Am J Surg 1976;132:19-21.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Odom FC, Oliver BB, Kline M, Rogers W. Gallbladder disease in patients 20 years of age and under. South Med J 1976;69:1299-300.  Back to cited text no. 9  [PUBMED]  
10.Diehl AK, Stem MP, Ostrower VS, Friedman PC. Prevalence of clinical gallbladder disease in Mexican-American, Anglo and Black women. South Med J 1980;73:438-41.  Back to cited text no. 10    
11.Khalil T, et al. Effect of aging on gallbladder contraction and release of cholecystokinin - 33 in humans. Surgery 1985;98:423-9.  Back to cited text no. 11  [PUBMED]  
12.Stampfer MJ, Maclure KM, Colditz GA, Manson JE, Willett WC. Risk of symptomatic gallstones in women with severe obesity. Am J Clin Nutr 1992;55:652-8.  Back to cited text no. 12  [PUBMED]  
13.Scragg R, McMichael A, Baghurst P. Diet, alcohol and relative weight in gallstone disease: A case control study. Br J Med 1984;288:1113-9.  Back to cited text no. 13    
14.Maclure K, Hayes K, Colditz M, Stampfer MJ, Speizer FE, Willett WC. Weight, diet and the risk of symptomatic gallstones in Middle-aged women. N Engl J Med 1989;321:563-9.  Back to cited text no. 14    
15.AR Al-Nuaim, K. Al-Rubeaan, Y Al-Mazrou 0, Al-Attas, N Al-Daghari, T Khoja. High prevalence of overweight and obesity in Saudi Arabia. Intern J Obes 1996;20:547-52.  Back to cited text no. 15    
16.Diehl AK. Epidemiology and Natural History of gallstone disease. Gastroenterol Clin of NA 1991;20:1-19.  Back to cited text no. 16    
17.Braverman DZ, Johnson ML, Kern Jr. F. Effects of pregnancy and contraceptive steroids on gallbladder function. N Engl J Med 1980;302:362-4.  Back to cited text no. 17    
18.Stauffer RA, Adams A, Wygal J, Lavery JP. Gallbladder disease in pregnancy. Am J Obstet Gynecol 1982;144:661-4.  Back to cited text no. 18  [PUBMED]  
19.Maringhini A, et al. Sludge and stones in gallbladder after pregnancy. Prevalence and risk factors. J Hepatol 1987;5:218-23.  Back to cited text no. 19    
20.Maringhini A, Ciambra M, Baccelliere P, Raimondo M, Pagliaro L. Sludge, stones and pregnancy. Gastroenterology 1988;95:1160-1.  Back to cited text no. 20    
21.Jorgensen T. Gallstones in a Danish population. Fertility period, pregnancies and exogenous female sex hormones. Gut 1988;29:433-9.  Back to cited text no. 21    
22.Minocha A, Greenbaum DS, Gardiner J. Effect of non­steroidal anti-inflammatory drugs on formation of gallbladder stones. Vet Hum Toxicol 1994;36:514-6.  Back to cited text no. 22  [PUBMED]  
23.Ahrendt SA, Ahrendt GM, Pitt HA, Moore EW, Lillemoe KD, Hypercalcaemia decreases bile flow and increases biliary calcium in the prairie dog. Surg 1995;117:435-42.  Back to cited text no. 23    
24.Lamarque D, Dutreuil C, Moulin C, Soule JC, Delchier JC. Pathogenesis of cholelithiasis in Chronic Pancreatitis. Gastroenterol Clin Biol 1992;16:869-74.  Back to cited text no. 24    
25.De-Las-Heras G, Gonzales-Bernal AC, Garcia D, Duenas C, Silvan M. Duodenal diverticula associated with acute pancreatitis. Rev Esp Enferm Dig 1994;85:349-53.  Back to cited text no. 25    

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Correspondence Address:
Khalid Rida Murshid
Department of Surgery, King Khalid University Hospital, P.O. Box 7805, Riyadh 11472
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864765

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  [Table - 1], [Table - 2], [Table - 3]



 

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