Saudi Journal of Gastroenterology
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Year : 1996  |  Volume : 2  |  Issue : 3  |  Page : 146-149
Gallbladder stones analyzes, bile and wound cultures in cholelithiasis

1 Department of Surgery, College of Medicine and Asir Central Hospital, Abha, Saudi Arabia
2 Department of Clinical Microbiology and Parasitology, College of Medicine and Asir Central Hospital, Abha, Saudi Arabia
3 Department of Clinical Biochemistry, College of Medicine and Asir Central Hospital, Abha, Saudi Arabia

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Date of Submission07-Mar-1996
Date of Acceptance03-Jun-1996


One hundred and fifty-two consecutive cases of cholelithiasis were studied. The gallbladder stones were analyzed to determine the constituents, the bile specimens were cultured and correlated with the cultures when wound infection occurred . Mixed gallstones were the commonest type (58.5%), pigment stones (27%) and cholesterol stones (14.5%). Positive bile cultures were found in 41 patients (27%) and Escherichia coli was the commonest organism isolated. The rate of wound infection was 14.5% and the most common organism cultured from the wound was staphylococcus epidermidis.

How to cite this article:
Malatani TS, Bobo RA, Al-Kassab AS, Al-Saigh AS, Ajao OG, Jastaniah S, Bhattachan CL. Gallbladder stones analyzes, bile and wound cultures in cholelithiasis. Saudi J Gastroenterol 1996;2:146-9

How to cite this URL:
Malatani TS, Bobo RA, Al-Kassab AS, Al-Saigh AS, Ajao OG, Jastaniah S, Bhattachan CL. Gallbladder stones analyzes, bile and wound cultures in cholelithiasis. Saudi J Gastroenterol [serial online] 1996 [cited 2022 Aug 16];2:146-9. Available from:

Cholecystectomy is the most common major abdominal operation performed on general surgical ward in this environment [1],[2],[3] . Various attempts to determine why this disease is so common in this environment have not been successful [4] .

Our objective is to study the constituents of gallstones and to define the rates of bile and wound infection in patients with gallstones, who underwent open cholecystectomy at Asir Central Hospital, a relatively new institution.

   Patients and Methods Top

One hundred and fifty-two patients with cholelithiasis underwent elective open cholecystectomy in Asir Central Hospital over a period of 12 months. None of these patients received prophylactic antibiotics. The gallstones obtained were allowed to dry at room temperature for about two weeks. There were weighed and crushed using a mortar, and the pulverized stone was assayed qualitatively using an Oxford Medical Systems stone analysis set (Lancer Company, Ireland). The assay for bilirubin in the stone was performed manually according to the method of Jendrassik and Graft [5] using a commercial kit purchased from Randox Laboratories (N Ireland). The results of chemical analysis of the stones were reported qualitatively as positive or negative. According to their major constituents, gallstones were classified into: mixed, pigment and cholesterol stones.

Gallbladder bile was taken at the time of surgery by needle aspiration before cholecystectomy. Immediately after aspiration, the bile was introduced into a Port-a-Cul vial (Becton Dickinson, Cockeysville, MD, USA) containing a reduced transport medium for dispatch to the microbiology laboratory.

On receipt in the microbiology laboratory, each bile specimen was aspirated from the transport vial and inoculated on two sheep blood agar (SBA) plates, one chocolate agar plate, one MacConkey agar plate and one thiogycolate broth tube. One SBA plate was incubated at 37C in an anaebore jar using the BBL GASPAK system (BBL Microbiology Systems, Cockeysville, MD, USA). All other media were incubated at 37C in an atmosphere of 5% carbon dioxide. The inoculated media were examined for growth at 24, 48, 72 hours and at the end of seven days after which the media were discarded as negative.

Isolate identification of facultative gram-negative bacilli was made using the API 20E identification system (Biomerieux, Marcy-I'Etoile, France). Anaerobes and all other isolates were identified using the standard methods outlined in the Manual of Clinical Microbiology, 4th edition, American Society of Microbiology, Washington DC, USA.

Any trivial discharge from the wound was considered as wound infection. Swab was taken and sent for aerobic and anaerobic culture.

   Results Top

Of the 152 patients whose gallstones were studied, 123 (80.9%) were females and 29 (19.1%) males, a female-male ratio of 4.2:1.0. The highest age group distribution was in the 4th decade. The median age was 41.7 years [Table - 1].

The result of the chemical analysis of the stones showed that bilirubin was the most common component present in 126 patients (82.9%), cholesterol in 108 patients (71.1%) and calcium in 90 patients (59.2%). Other components found were uric acid, magnesium, carbonates, oxalate and cystine. However, classifying the stones into three major groups depending on their major components, mixed stones were found in 58.5% of the patients; pigment stones in 27% and cholesterol stones in 14.5% [Table - 2].

Bile cultures, performed both aerobically and anaerobically, showed positive culture in 41 patients (27%). Nine out of those 41 patients (22%) had acute cholecystitis and the remaining had chronic cholecystitis. The most common organism cultured was E. coli (26.8%) of the positive culture, followed by Klebsiella spp. (19.5%) [Table - 3].

Of the 41 patients (27.0%) with positive bile cultures for bacteria, the types of gallstones were mixed in 21 (51%), pigment in 15 (37%) and cholesterol in five patients (12%).

None of our patients received prophylactic antibiotics and the wound infection occurred in 22 patients (14.5%). Out of this, seven patients had acute cholecystitis and the remaining had chronic cholecystitis. The commonest organism were Staph. epidermidis (27.3%) of the infected wound [Table - 4]. Apart from Staph. epidermidis the other bacteria isolated from wound cultures did not correlate well with the organisms isolated from the bile cultures.

In this series, gallstones were associated with histopathologically proven chronic cholecystitis in 120 patients (79%) and acute cholecystitis in 32 (21%). None of the patients had hemolytic disorders.

   Discussion Top

In this environment, biliary tract disease is more common in women than men with a ratio of 4.2:1 and seen in a younger age group. Similar findings were seen in King Khalid University Hospital, Riyadh [1] . In western series the peak incidence of symptomatic cholelithiasis occurs in the fifth and sixth decades [6],[7] . A report from Belgium [8] showed a male-female ratio of 3:1 and mean age of 51 years. The incidence of positive bile culture in this series was 27% which is comparable to the findings of other workers [9],[10],[11] .

Our findings agree with that of other workers that E. coli is the most common organism isolated from bile cultures [12],[13],[14] . The spectrum of the bacteria isolated from the bile in this group was generally similar to those in other reports. This series also confirmed the work of others (15,16), that the presence of bacteria in the bile did not seem to influence the incidence of wound infection.

The incidence of wound infection in many studies after elective open cholecystectomy in patients without prophylactic antibiotics coverage appears to be between 15 and 28 percent [17],[18],[20] . Our results are within that range.

As far as etiology of gallstones is concerned the incidence of positive bile cultures for bacteria (27%) of all the 152 patients with cholelithiasis is too low to conclude that infected bile played a major role in the formation of cholelithiasis in general. However, bile infection was documented among 51 and 37% of patients with mixed and pigment stones, respectively.

Seventy-three percent of patients showed sterile bile culture. In patients with wound infection, the wound culture did not correlate with the bile culture. In conclusion, in this study the most common type of gallstones was mixed stones. Pathogenesis seems to be well correlated with bile infection.

   References Top

1.Mofti AB, Al-Tameem MM, Al-Khudairy NN, Singh DN, Ahmad IA. Experience with elective cholecystectomy in King Khalid University Hospital. Ann Saudi Med 1987;7:107-10.  Back to cited text no. 1    
2.Al Sulaimani SH, Alam MK, Sengupta H, Girgis A. Incidence of cholelithiasis in patients attending King Abdulaziz University Hospital. Saudi Med J 1986;7:261-5.  Back to cited text no. 2    
3.Tamimi TM, Wosornu L, Al Khozaim A, Abdul-Ghani A. Increased cholecystectomy rates in Saudi Arabia. Lancet 1990;336:1235-7.  Back to cited text no. 3    
4.Al-Kassab AS, Malatani TS. The pattern of serum biochemical abnormalities in patients with gallstones. Eur J Clin Chem. Clin Biochem 1992;30:21-5.  Back to cited text no. 4    
5.Jendrassik KL, Grof P. Vereinfachte photome-triche methoden zur Bestimmung des Bluntbilirubins, Biochem Z 1938;297:81-6.  Back to cited text no. 5    
6.Crumplin MK, Jenkinson LR, Kassab JY. Management of gallstones in a district general hospital. Br J Surg 1985;72 (6):428-32.  Back to cited text no. 6    
7.Bennion LJ, Grundy SM. Risk factors for the development of cholelithiasis in man (second of two parts). N Engl J Med 1978;299(22):1221-7.  Back to cited text no. 7    
8.Elewant A, Crape a, Afschrift M, Pauwels W, De-Vos M, Barbier F. Results of extacorporeal shock wave lithotipsy of gallbladder stones in 693 patients: a plea to restriction to solitary radiolucent stones. GUT 1993;34:274-8.  Back to cited text no. 8    
9.Truedson H, Elmros T, Holm S. The incidence of Bacteria in gallbladder bile at acute or elective cholecystectomy. Acta ChirScand 1982;194:308-12.  Back to cited text no. 9    
10.Glen P, Joffe SN. Bacteria in the bilairy tact. Contemp Surgery 1985;27(l):25-9.  Back to cited text no. 10    
11.Keighly MRB, Mcleish AR, Bishop HM. Identification of the presence and type of biliary microflora by immediate gram stains. Surgery 1977;81:469-75.  Back to cited text no. 11    
12.Van-Steenbergen W, Rigauts H, Ponette E, Peetermans W, Pelemans W, fevery J. Percutaneous transhepatic cholecystostomy for acute complicated calculous cholecystitis in elderly patients. J Am Geriatr Soc 1993;41:157-62.  Back to cited text no. 12    
13.Janowitz P, Janowitz A, Schumacher KA, Wechsler JG, Ditschuneit H. Occult gallbladder perforation: an unusual complication of gallstone lithotripsy. Hepatogastroenterology 1992;39:43-6.  Back to cited text no. 13  [PUBMED]  
14.Prevot L, Breslev L, Muller C, Boissel P, Grosdidier J. Bacteriological aspects of acute cholangitis with gallstones. Presse Med 1991;20:689-91.  Back to cited text no. 14    
15.Grande M, Torquati A, Farinon AM. Wound infection after cholecystectomy. Correlation between bacteria in bile and wound infection after operation on the gallbladder for acute and chronic gallstone disease. Eur J Surg 1992;158:109-12.  Back to cited text no. 15    
16.Lai CW, Chan RC, Cheng AF, Sung JY, Leung JW. Common bile duct stones: a cause of chronic salmonellosis. Am J Gastroenterol 1992;87:1198-9.  Back to cited text no. 16  [PUBMED]  
17.Kaufman Z, Engelberg M, Eliashiv A, Reiss R. Systemic prophylactic antibiotics in elective biliary surgery. Arch Surg 1984;119:1002-5.  Back to cited text no. 17  [PUBMED]  
18.Lewis RT, allan CM, Goodall RG. A single preoperative dose of cefazolin prevents postoperative sepsis in high-risk biliary surgery. Can J surg 1984;27:44-8.  Back to cited text no. 18    
19.Cainzos M, Potel J, Puente JL. Prospective randomized controlled study of prophylaxis with cefamandole in high risk patients undergoing operations upon the biliary tract. Surg Gynecol Obstet 1985;160:27-32.  Back to cited text no. 19    
20.Keighly MRB, Lister DM, Jacob SJ, Giles GR. Hazards of surgical treatment due to microorganisms in the bile. Surgery 1974;75:578-83.  Back to cited text no. 20    

Correspondence Address:
Tarek S Malatani
Associate Professor of Surgery, King Saud University, Abha Branch, P.O. Box 575, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

PMID: 19864823

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  [Table - 1], [Table - 2], [Table - 3], [Table - 4]


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